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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> SFIF:ICE USE: APPLICATION. mM, <br /> (For Non-Transferable, Revocable, Suspendable) <br /> + P MR& 1, -� <br /> ENVIRONMENTAL HEALTH PERMIT �i `� ! <br /> ,. <br /> (COMPLETE IN TRIPLICATE) 12 `77 - .�� M Eson1 WATER QUALITY ��'— rho— DE �pplicr <br /> Application is hereby madeto the San Joaquin Local Health Districtfora permitto construct and/or installthework herein described.Thisn i <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address t# IIo'nd of Jameson Rd- - City/Town 100n.teCa <br /> Owner's Name <br /> Tony Fa cebo - Phone <br /> Address 151,T71 ' 1T.0 one s City Manteca <br /> 24 <br /> Contractor's Name I"ac a O• 00 License#377040 Business Phone 2"1 24 <br /> Contractor's Address '� ' C ' 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❑ DESTRU.CTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 99 PUMP REPAIR❑ <br /> REPLACEMENT <br /> DISTANCE TO NEAREST: Septic Tank e0y Sewer Lines_ Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL 'S ❑ 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 T <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: I Contractorac "` o ; C' <br /> Type of Pump ' H.P. <br /> iff <br /> PUMP REPLACEMENT: 13 State Work Done B an rep a,Ce pump &X'� ��� <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 <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certilies 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 certilies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting antl a final inspection. <br /> Signed Xi / ` °' Titley f �. .,- Date: <br /> (Draw Plot Plan on Reverse Side) <br /> P <br /> FdR DEP RTMENT USE ONLY <br /> ¢ PHASE I <br /> Application Accepted By ``4' � ` ' <br /> !/ Date <br /> Additional Comments: <br /> Phase li Grout Inspection Phase III Final Inspection <br /> Inspection By Y- Date - Inspection By "Date^ - �- - <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE i,Ati - �.:+L,.r A�,J`# r rf}•"''C {�^ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER u <br /> OTHER <br /> -7q <br /> Received by at Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />