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PUMP—&—VstEa FOR OFFI.5E-115... <br />Applications Will Be Processed When Submitted Properly Ucimpietea. De <br />QUI C • <br />APPLICATION <br />(For Non-Transterable, Revocable, Suspendable) <br />ENVIRONMENTAL HEALTH PERMIT <br />Well <br />PUMP REPLACEMENT: <br />PUMP REPAIR: <br />DESTRUCTION OF WELL: <br />(COMPLETE IN TRIPLICATE) <br />WATER QUALITY <br />Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described. This application is <br />• <br />made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br />W Grantlin.e Rd.-600' East of ChrttigliklInRA±4A_Iorth side <br />835-7316 <br />ine Rd <br />s Bros. <br />urance on File With SJLHD? Yes <br />c-D <br />Other <br />INTENDED USE <br />El INDUSTRIAL <br />ICI DOMESTIC/PRIVATE <br />DOMEST1C/PUBLIC <br />IRRIGATION <br />El CATHODIC PROTECTION <br />DISPOSAL <br />GEOPHYSICAL <br />PUMP INSTALLATION: <br />- - <br />Date <br />ection <br />ate <br />ID PER UNI' <br />AMOUNT DUE <br />REMITTED <br />FEE <br />PLUS PENALTY <br />OTHER <br />OTHER <br />Exact Site Address • <br />Owner's Name Silva Bros. Dair <br />Address ---731 7 We Grant <br />C ntractor's Name Rennin <br />Contractors Address3 5 25.___Relandale• <br />NEW 4. DEEPEN 0 RECONDITION 0 DESTRUCTION 0 Compensation s <br />WELL ABANDONMENT 0 OTHER 0 PUMP INSTALLATION fl PUMP REPAIR 0 <br />Septic Tank 1 1 30 / Sewer Lines ____ Pit Privy <br />_1 _ Cesspool/Seepage Pit <br />Is Certificate of Workman's <br />TYPE OF WORK (CHECK): <br />WELL CHLORINATION 0 <br />REPLACEMENT 0 <br />DISTANCE TO NEAREST: <br />Sewage Disposal Field _ <br />Property Line__ Private Domestic Well Public Domestic Well <br />I TYPE OF WELL <br />CABLE TOOL <br />J O DRILLED <br />DRIVEN <br />CI GRAVEL PACK <br />ROTARY <br />OTHER <br />Cont ctor <br /> <br />1111111 — <br />License # <br />City_ 'frac <br />29081 3 Business Phone <br />(tide_S--t-0--- Emergency Phone _ L. -02 <br />Dia. of Well Excavation <br />Dia. of Well Casing <br />Gauge of Casing — 16Q WALL <br />Depth of Grout Seal <br />Type of Grout CEMENT \J <br />Other Information SLAB-BY OWNER <br />Surface eal Installed By: DRILLER <br />1 <br />• <br />Phone <br />6" PVC <br />Sta <br />Work Done <br />k Done <br />et <br />I will call for a Grout Inspection prior to grouting and a final inspectio <br />I Signed X HENNINGS <br />PHASE I <br />Application Accepted By <br />Additional Comments: <br />Fee Is Due: El ANNUALLY <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 <br />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 <br />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 />SEC .. Date: 5-1 5-80 <br />Inspection By <br />se II Gr <br />0 PER SITE 0 EACH <br />aw Plot Plan on Reverse Side) <br />FOR DEPARTMENT USE ONLY <br />Ofik- <br />-f-Likee) <br /> Inspection By 6se ltl Fi Inspeilion <br />Date <br />0 January 1 & Receved By January 31 0 Jwy 1 & Received By July 31 - <br />REMIT <br />CHECKED <br />AMOUNT <br />1-44410 <br />33/C) <br />Received oy Date • Receipt No Permit No <br />4.' <br />APpLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM1T/5E1VICES <br />LESS PRORATION <br />Issuance Date Maeed 0 red <br />1601 E. HAZELTON AVE., P.O. Boa 2009 ODIcTON, CA 95201 <br />Approximate Depth <br />5'45-1 8 5