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Applications Will Be Processed When Submitted Properly Completed. �S�1►�e� t oApup <br /> . �t� <br /> oR ofFlcr� USE: APPLICATION , � (����' <br /> (For Non-Transferable, Revocable, S d'aT�le) <br /> &WELL <br /> ENVIRONMENTAL HEALTH MI�U G 23 1979 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the SaWJo quinLocalHealthDistrictforapermittoconstructarISl�Nnslk-flk!lnrSNhbQG&scribed.Thisapplicationis <br /> made in compliance with San Joaqounty Ordinance No. 1862 and the rules and regulatigl4f,(A th��arDj&-&iR�CL-Xcal Health District. <br /> Exact Site Address City/Town 1 001 , CA <br /> Owner's Name MRS. MARY EERRERO Phone <br /> Address 7580 W. MCKINI FY _ City FRESNO, CA <br /> Contractor's Name _SAN JOAQUIN P1JMP CQ. License# RX{ 31 a78Business Phone 369-8471 <br /> Contractor's Add res�h(1 E. PTNF ST 1 MT Emergency Phone 3.69-8471 V <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes NoAN <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ N <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR QXX <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 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 ❑ 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 Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 1PXState Work Done PI-11 1- 2 HP SURMFRSTRI F PI IMP FOR REPAIR <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 /> 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 forwhich 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 pr or to grouting and a final inspection. <br /> 1 (� <br /> Signed X� �~ Title: 4 Date: <br /> (Draw Plot Plan on Revel' Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI - <br /> Application Accepted By Date 7 <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase I Fin nspectfon <br /> Inspection By 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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 7 ��tSZ <br /> Received by I Date Receipt No. Permit Na. issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95261 <br /> c -� <br />