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., Applications Will Be Processed When Submitted Properly Co Fee d. o Sign The Application. <br /> FOR OFFICE USE: ,,. APPLICA ��I V , <br /> f_ (For Non-Transfer e,�F�e abiil, Suspendable) 1 <br /> ENVIRONME L,HEAL`�� 1� 11`T PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) W Uillil ���' <br /> AppIicationisherebymadetotheSanJoaquinLocal HeaithDistrictforapermit toconstt�y 1) 6164Ytework herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1852 and the r 1&s.�nc�`f1�la�of the San Joaquin Local Health District. <br /> Exact Site Address�At t-h end of J mactnw_e_pn__Rd_ Its -�� City/Town Martitana <br /> Owner's Name Tony Mancebo <br /> Phone <br /> Address 9'7 So. Jack- Tone Rd. City Manteca <br /> Contractor's Name Machado, Inc.' License# 377040 Business Phone 462-1424 <br /> Contractor's Address No Jack Tone R • Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ ' <br /> WELL CHLORINATION ❑ WELL ABANDONMENT C1 OTHER C1 PUMP INSTALLATION IN PUMP REPAIR❑ — '4 <br /> REP!_ACEMENT O <br /> r � <br /> DISTANCE TO NEAREST: Septic Tank aQ r Sewer Lines #' Pit Privy <br /> Sewage Disposai Field -Cesspool/Seepage Pit Other_ 3 <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE I TYPE OF WELL <br /> D INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ 'DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ ;DRIVEN Gauge of Casing ; { <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth'of Grout Seal <br /> ❑ CATHODIC'PROTECTION ❑ ROTARY' Type of Grout_ <br /> ❑ DISPOSAL ❑ OTHER - Other Information <br /> ❑ GEOPHYSICAL t Surface Seal Installed-By: r� <br /> PUMP INSTALLATION: Contractor Machadoy.rinc. <br /> Type of Pump - H.P. f� <br /> PUMP REPLACEMENT: ❑ State Work Done t?d and rep- F3eed pump AX <br /> C ? <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter --- _ Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County i <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I wil or a Grout In �c�n,,prior to grouting and a final inspection.- Date:Signed 'Title- y <br /> « <br /> (Draw Plot,Plan-oneverse Si e) <br /> FOR DEPARTMENT.USE-ONLY,,.�,� F <br /> PHASE I `r <br /> q j <br /> Application Accepted By Date 7/ <br /> Additional Comments: <br /> Phase II Grout Inspection _ _- _ ; se III F' al Inspection <br /> Inspection By 4 �y Date m Ins'sp tion By Y Date Z2- <br /> Fee <br /> Z ' <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 k <br /> REMIT <br /> -BILLING REMITTANCE $ f <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> 44 <br /> FEE r � <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> � S rj <br /> ­79�1�i4:ca 1\I's /7G <br /> Received by Date Receipt No. Permit No. ss�uance Date , Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E--HAZELTON AVE.,P.O:Box 2009 STOCKT N,CA 9.520 <br />