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Applications Will Be Processed When Submitted Properly Compleledif6 S& _94hf6�p�ati� 1. <br /> Foto OFFICE USE: APPLICATION I f 11 <br /> (For Non-Transferable, Revocable, Suspendable) JAN 14 1980 �J <br /> a PUMP&WELL + <br /> ENVIRONMENTAL HEALTH PERMIT /� <br /> (COMPLETE 1N TRIPLICATE) t WATER QUALITY `SAN��ppJQAQUiN �RRC��}eA� Q <br /> Application is hereby made to the San Joaquin Local Health Districtfora permitto construct and/oriristaE9 tfT�WrA%Tr%alribed.This application is <br /> made in compliance with San Joaquin County Ordinance No.1862 and the rules and regulations of the San J Loa] Health District. <br /> Exact Site Address A:- City/Town _elsei AL-/1 <br /> Owner's Name RON AQ T &zso .­, Phone R-3t3—2-3/ 7 <br /> Address City <br /> Contractor's Name License Q Buss s Phone_ M <br /> Contractor's AddreEmergency Phone pll-� <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes� No t <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION Lr DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENTOTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ 4.1) ccW. etL V,,k L 'S e42 Z-0 <br /> DISTANCE TO NEAREST: SeptOTank40 4pN,6 P, Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well 11 <br /> INTENDED USE 11 TYPE OF WELL <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation <br /> P1 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 Su face Seal Installed By: <br /> PUMP INSTALLATION: Contractor � a�J <br /> Type of Pump 61, H,P. <br /> PUMP REPLACEMENT. ❑ State Work Done l , <br /> PUMP REPAIR: © State Work Done 1V <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 worn will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. r; <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit A L <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." <br /> 11 <br /> I will c _r a Grou=1' Io grouling and a sinal inspec 'Signed X . , � ry` Title: amu` Date" <br /> (Draw Plot Plan on everse Side) <br /> FO DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Dated <br /> Additional Comments: <br /> _VL0 <br /> Phase 11 Grout Inspectionase III Final inspection <br /> Inspection By Date Inspection B Date -� <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July i &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNTDUE CHECKED <br /> AMOUNT ! <br /> FEE 4S 7 <br /> LESS } <br /> PRORATION } <br /> PLUS <br /> PENALTY <br /> OTHER i I <br /> OTHER Ii <br /> Ali <br /> f <br /> 1�IgLso- I zvT 103,336 . <br /> Received by Date Receipt No, Permit No. - Issuance Date Mailed Delivered <br /> -APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 457,67" <br /> } \ i <br />