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Applications Will Be Processed When Submitted ProperlyCompleted. BeSureT SignTheApplicwo ' <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspend a�l } X980 <br /> N `�CAQU PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIA*ICIL-. 11� <br /> (COMPLETE IN TRIPLICATE) (P-SS 4 �C€-moi= � TER QUALITY H flls'rR/CLOCAL <br /> Application ishereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No.1862 and the rules and regulati ns of the San Joa4uin cal Health District. <br /> Exact Site Address 1 ,SOut " KettleMan Llft;i i East Curry R ity/Town �'O� <br /> Owner's Name J OM Kant Z Phone <br /> Address 5490 E.. Bear Creek City e � <br /> Contractor's Name Fur- viance Drillers Drillill&ense# 377923 Business Phone 9 1" 1 <br /> Contractor's Address P. Q. - Box Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes XXX No t <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITIONZI DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> ,f <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br />_ Sewage Disposal Field Cesspool/Seepage Pit Other <br /> f Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL 99 CABLE TOOL Dia. of Well Excavation <br /> li tt I <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 22 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> []' DISPOSAL ❑ OTHER Other Information + <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor i <br /> Type of Pump H.P. r <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure �% <br /> i <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 certifies the following:"I certify that in the performance of thework for which this permit 1 <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." aC <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 will call,for a G ut 5,tRion prior to grouting and a final inspection. I <br /> President 3/4/80 <br /> Signed X Titte: - Date: <br /> (Draw Plot Plan on Reverse Side) <br /> F DEP TMENT USE ONLY <br /> PHASE # <br /> Application Accepted By �� ­- Date <br /> I <br /> Additional Comments: <br /> Phase 11 Grout InspectionP 111 Finai spection <br /> Inspection By Date 1114— 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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE Af DATE REMITTED <br /> AMOUNT t <br /> - - I <br /> dA <br /> FEE r M <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> i <br /> OTHER ' <br /> OTHER <br /> Received by Date I Receipt No - Per it No. Is uance ate Mailed Delivered <br /> - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,C- <br /> �* . . . u...v-- ..-u. -.. - AVE:, <br />