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Applications Will Be Processed When Submitted Properly Completed. Be Sure To! hAp�ic olI �; <br /> FOR OFFICE USE: APPLICATION tb 4i <br /> (For Non-Transferable, Revocable, Sus endable <br /> p <br /> ENVIRONMENTAL HEALTH PERMIT Mduia,!"LL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY �- f;i <br /> ��i� � �1 �..I.,>� L00� <br /> Application is hereby made to the Sa n Joaq ui n Local Health D istrict for a permit to construct and/orinstallthe work ItLdslnk� � -Cation is <br />'`. made in compliance with San Joaquin County.Ordinance No 1862 and the rules and regulations of the an Joaquin Local Health District. <br /> Exact Site Address 29980 E Vine - City/Town ES_CF1.1 nn <br /> Owner's Name Russ Hannick Phone 838-1340 <br /> Address Same City <br /> Contractor's Name I.J. Larsen Pumps, Inc. License# 276660 Business Phone 529-2020 <br /> Contractor's Address 509 Tully Road, Modesto Emergency Phone r <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 ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENTZ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Linesr' Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well I 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 11 <br /> ❑ GEOPHYSICAL Surface Seal Installed By: j <br /> PUMP INSTALLATION: Contractor t� <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done pu11 dump & replace 1 HP sub motor <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth J <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 /> #tome owner or licensed agent's signature certifies the following:A 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 persons subject to workman's compensation laws of California." JJ <br /> I wi II for a Grout Ins ction prior to gXog and a final inspection. f <br /> Signed X 4 Title: service Date: 1/4/83 <br /> raw Plot Plan on Reverse Side) <br /> 3.. <br /> -4 <br /> FOR DEPARTMENT USE ONLY / <br /> PHASE I /«��' y -97-3 <br /> Application Accepted By j` Date <br /> Additional Comments: <br /> Pha 11 Grout Inspection has 111 Final Inspectio <br /> Inspection By Date Inspection By Date <br /> '7 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILL+NG REMITTANCE $ REMIT j <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED 9� <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER 3 <br /> I 13r � � <br /> Received by by D to Receipt No. Permit No. IssuancetDate Mailed Delivered _ I <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 ,;y, <br />