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Applications Will Be Processed When Submitted Properly Completed. B en" leplic3tFbn. <br /> 'c==POR OFFICE USE: APPLICATION <br /> ^H (For Non-Transferable, Revocable,Suspendable) DEC 19 179 P&WELL <br /> f PUM <br /> ENVIRONMENTAL HEALTH PERMIT <br /> ` SAN JOAQUIN LOCAL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY HEALTH DlST�iGT � <br /> Application is hereby made tathe San Joaquin Local HealthDistrictforapermittoconstructand/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1852 and the rules and regulations of the San Joaquin LocaJ Health District. <br /> Exact Site Address 1500 ft, off Steinul City/Town � rJ. <br /> Owner's Name Hogan & Laguero Enterprise Phone <br /> Address City I <br /> i <br /> Contractor's Name Stanislaus Pump License# A299355 Business Phone 209 522-9027 j <br /> Contractor's Address PO. Box 6125, Modesto, Ca. Emergency Phone Same if <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN ❑ RECONDITION DESTRUCTION❑ X <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ® PUMP REPAIR❑ II <br /> REPLACEMENT❑ ' <br /> t DISTANCE TO NEAREST: Septic Tank <br /> P Sewer Lines Pit Privy <br /> Sewage Disposal Field - ' •-� "Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well r <br /> INTENDED USE TYPE OF WELL _ <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation !! CA <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing j 8 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 12 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ;I <br /> © CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information IJL <br /> i ❑ GEOPHYSICAL Surface Seal Installed By: r <br /> PUMP INSTALLATION: Contractor Stanislaus Pump & Machinery <br /> Type of Pump TilrbineH p - 0 <br /> PUMP REPLACEMENT: ❑ State Work Done li (� <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth �t <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 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 j <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." j <br /> I wl1(call for a Grout Inspection prio to grouting and a final inspection. I <br /> Signed X CI.J .Title: Date: <br /> (Draw Plot Plan-on Reverse Side)------" —- - i <br /> FO DEPARTMENT USE ONLY j <br /> PHASEI <br /> Application Accepted By Date U <br /> Additional Comments: 1� <br /> Phase II Gro t spection Phase III Final Inspection j <br /> Inspection By- __ Date. inspection B Date_; <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 15k-PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 30 <br /> RASE EXPLANATION <br /> BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> _ <br /> FEE <br /> LESS <br /> II <br /> PRORATION <br /> PLUS <br /> PENALTY l <br /> OTHER <br /> I! <br /> OTHER <br /> 1 <br /> II <br /> Received by Date - Receipt No. Permit No. 03 <br /> Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES , ,j 601 E.HAZELTON AVE.;P.O.Box 2009 STOCKTON,CA 95201 <br />