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f Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ,.oR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMA&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) .S,gWQUALITY OS�- <br /> f, Application is hereby made to the San i6ag61ri-Local H&alth 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 regulations of the San Joaquin Local Health District. <br /> Exact Site AddressN.E. Corner Lower Sacto and Harney City/Town <br /> Owner's Name Tom Katzaki an. . Phone_0�j9-241 <br /> a Address 13520 Lowery Sacs amento Rd City I <br /> Contractor's Name Noack Pump Co: License# 355213 Business Phone_ 8-$$17 <br /> Contractor's Address 4500 E,. Fremont, Stockton Emergency Phone Same' <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK {CHECK): NEW WELL <br /> 11 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION0 PUMP REPAIR❑ <br /> { REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy O ` <br /> Sewage Disposal Field Cesspool/Seepage Pit Other G <br /> Property Line ;Private DomeStic`We11—" Put5lic Domestic'Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED pia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> I ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL I Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Noack Pump Co. <br /> Type of Pump Submersible H.P. 3 <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 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 /> { <br /> Homeowner 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 for which this <br /> permit is issued, i shall employ pers ns subject to workman's compensation laws of California." <br /> I will c 11 0C �s�g�outlng and a final inspection. <br /> Signed X JOE BORGES Title: SERVICE MANAGER Date: 28 MAY 1981 <br /> -(Draw Plot Plan on Reverse Side)- -----� -- r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By �PY41Date <br /> Additional Comments: <br /> I Phase 11 Grout Inspection Pha III Final Inspection <br /> Inspection By Date Inspection B t 17f Dat <br /> Ifok <br /> Fee Is Due: ❑ ANNUALLY [I PER UNIT ElPER SITE ' ElEACH ❑ January 1 &Received lay January 31 ❑ Jufy 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> ' FEE S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY _ <br /> OTHER <br /> OTHER -" <br /> t Received by Date Receipt No. Permit NoIssuance Date Mailed Delivered <br /> ILL APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM ITISERYICE5 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> r <br />