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A 444.0 libaw wiM 04 rrww"44 w0wh ahalra"iiu..l re�plel►.Ie llri"TI*�'Ylsw♦h.pp.lw.awr., l <br /> roil OFFICE usE: APPLICATI ' l <br /> (For NOWTransleraw. ) 7 y�P d.WELL <br /> ENVIRONMENTAL HEA MAN I! <br /> m WATER WAUTT <br /> APplioatlon is hereby made to the San Joaquin Local Health DIWrW for a permit to eonsGANnd'a4ANMI Me Not K,gtiln described.This application is <br /> made M aomp9ana trhft San Joaquin County Ordiname No.1902 and the rules and r/d111"if4Of Uf 1-;ff,'4M.,)n Local Health District, <br /> 921ao1 alb Addireas City/Town <br /> Owners Nam AFt/1.1/• Phone /° ? <br /> �AddrMa 5�3� �e fi city 1 �✓ <br /> Convactiora Noma--�rIL_ �i ..a ..� Licensell U-j I3 Buslneas Phone_-_ Yl-/ <br /> Contraalli Address �' `r Emergency Phone <br /> fit Celtft@ft of Workman's,Compensation Insurance on FIN WHlI SJLHD9 Yes No ------- r <br /> TYFa OF WIM(CHECK): NEW WELL D DEEPEN 17 RECONOITIOND DESTRUCTION❑ (j <br /> WELL'CHLORINATION O WELL ABANDONMENT O OTHEp CI PUMP INSTALLATION 0 PUMP REPAIR❑ yC <br /> K.?U1 r611ENT O lJ <br /> DISTANCE TO NEAIIEST: aspoe Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Css,spool/Ssepage Pit --_-_- Other �. <br /> P10PWtY Una Private Domedic Well Public Domesuc Well <br /> TYPE OF WELL <br /> L 13 CABLE TOOL Dia.of Well Excavation <br /> OOMESTtai/PRIVATIE O DRILLED Dia.of Well Casing <br /> O DOMESTICdPUBLIC ' Q ORIVEN Gauge of Casing ---.-- --- '"S <br /> O IRRIGATION 17 GRAVEL PACK Depth of Grout Seal <br /> O CATHODIC PROTECTION O ROTARY Type of Grout _ <br /> O DISPOSAL O OTHER _ Other Information - <br /> O GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor _ <br /> Type of Pump H.P. <br /> FtilfilP RE/LACRMEt1T: D State WO�h Done -.j <br /> .Ft1111bP REPAIR: f3 State Werk Dons <br /> DESTRUCTION OF WELL: wall Diameter Appr,Aimate Depth <br /> Describe Material and Procedure <br /> 1 hereby certify that I Rave prepared,this application and that the work will be done in accordance with San Joaquin County <br /> ord;narxm.state laws,and rules and Isgulations of the San Joaquin Local Health District. <br /> 1, HOPN alw»r or licenced aged sipWAMO Certifies the IotlowbW"I certify that in the performance of the work for which this permit <br /> +p1 is issued, I stall not employ any perron In such manner as to beccme subject to workman's compensation laws of California." <br /> C06111raabee k"orsub-oankac q s4pour000t#o"ow blowing:"I certify that in thL performance of the wcrk for which this <br /> permit is 1swied.I$hat:employ persons subject to workman's compensation laws of California." <br /> 1 wQ CON fora Grout WMPOCtien Prior ad,groutlrq and a f sil Inspection. F :M <br /> f Signed X - ON,,; t7- A n..,... (t -1'l� .t,t=_-.}T� /Yl�• : Daw. I ? <br /> (Draw Plat Plan on Reverse Sidef <br /> + FOR DEPARTMENT USE ONLY <br /> /WASE: 1 <br /> Application Accepted By <br /> Additional Comments: _ <br /> Phaea II Groul Irlspet:tlort Phast III Final Inspection 7 <br /> Inspection By Date In .-- _ <br /> ePection B y __1��.� Date Y <br /> a r <br /> ( FJd IS Due:❑ ANNUALLY Q HEA UNIT ❑ PfP SITE ❑EACH ❑ Jwuwy 1 l Recerred By January 31 July t Recalled By July 31 <br /> — ----------- -----REMIT <br /> j <br /> BILLING REYITTA:JCF f BASE EXPLANATION AMOUNT DUE CHECKED <br /> GATE DATA REMITTED AMOUNT <br /> FEELESS <br /> PRONATION <br /> PLUS — --- - <br /> PENALTY <br /> OTHER <br /> OTHER - <br /> S <br /> OMe Rep,pl No. — PerRwl No. 1 nc.Gate ---waed --OMwerW , <br /> APPLACANT-RETUIW ALL COPIn TOt psnisoes/EMTAL M"T"PWAUT/allty cu /MI C NAZELTON AYE..P.O.esu 2000 STOCKTON,CA 96W <br /> K <br /> Sy, S <br /> 4x� � <br />