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_e-Pr eA When Submitted Properly� 111 ,� LTD <br /> A i tib i11`se P APPLICATION 9 <br /> {-OR OFFJCE USE: �l CO Fpr y� lLransferable, Revocable,Sus le)JAN 21 198 i QUM�&WALL 4. <br /> �`� U LLQ <br /> ,gyp`bNMENTAL HEALTH PERMIT <br /> \A WATER QUALITY SAI' <br /> (COMPLETE IN TRIPLICATE) ` HfiA 11'Wor�R��� ��cribed.This application is <br /> Application is hereby made to the SanJoaquityOrdin Local once Districtforrut s construct reg lation STOCKTON <br /> in compliance with San Joaquin County Ordinance No. if362 and the rules and regulationsf the Joaquin Local Health District. <br /> made p 6570 E. EIGHT MILE ROAD <br /> Exact Site Address Phone 931-1055 „ <br />+ WILBUR C. LEFFLER City STOCKTON CA 95212 <br /> owner's NameTGNT -DILE R AD 948-8817 <br /> Address License# 35l Bus15eAE hone i <br /> Contractor's Name NOACK PUMPS <br /> Contractor's Address 450 E. FRERU1`j ST. STOCKTON Emergency Phone No <br /> ❑ DESTRUCTION❑ <br /> D? Yes <br /> Is Certificate of Workman's Compensation 1n❑surancDeEEpEN�With SJRL CONDITION � PUMP <br /> REPAIR❑ <br /> TYPE OF WORK (CHECK): NEW WELL <br /> WELL CHLORINATION❑ WELL ABANDONMENT ❑ OTHER- 0 PUMP INSTALL r <br /> REPLACEMENT 13sewerLines Pit Privy <br /> �� '�� Others <br /> DISTANCE TO NEAREST: Septic Tank Sewage <br /> Pit <br /> Sewage Disposal Field public Domestic Well <br /> Property Line Private Domestic Weht <br /> f <br /> INTENDED USE TYPE OF WELL <br /> ❑ CABLE TOOL Dia. of Well Excavation <br /> C ❑ INDUSTRIAL [I DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PRIVATE C3 DRIVEN Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ IRRIGATION ❑ ROTARY Type of Grout <br /> ❑ CATHODIC PROTECTION Other Information <br /> ❑ DISPOSALr ❑ OTHER } <br /> * t Surface Sea; Installed By: <br /> ❑ GEOPHYSICAL NOACK PUMPS t <br /> Contractor }{,p, 5 <br /> PUMP INSTALLATION: Type of Pump SUBMERSIBLE - - <br /> rt <br /> ❑ State Work Done I <br /> PUMP REPLACEMENT: ❑ State Work Done Approximate Depth <br /> PUMP REPAIR: Well Diameter { <br /> DESTRUCTION OF WELL: <br /> Describe Material and Procedure <br /> l herebycertify that I have prepared this application <br /> and-that the he San Joaqu noLocalrk llHeabe Rh District one in accordance with San Joaquin County'- ordinances, state laws, and rules and regulations oft y certify thatintheperformanceofthe work for <br /> whichihispermit <br /> Horne owner or licensed ageni's signature certifies the following Y <br /> r is issued, I shall not employ any person in such manner as to become I certify thasubject to lt nrthe performance of thecompensation <br /> Contractor's <br /> foaws of Cwlh ch this <br /> Contractor's hiring or sub-contracting signature certifies the following:' <br /> permit is issued, I shall employ n laws of California." <br /> persons subject to workman's compensatio <br /> I will call for a Grout inspection prior to grouting and a final inspection. 19 JAN 1981 <br /> Title: <br /> SERVICE MANAGER Date: <br /> -- '� <br /> t BORGES Signed X E <br /> f. � (Draw Plot Plan on Reverse Side) <br /> 4, F <br /> RD PARTM'E 'T USE ONLY /y <br /> Date <br /> FA ' <br /> � --' .- <br /> n Accepted By <br /> al Comments: ease 111 Final Inspection <br /> Phase tl Grout Inspection - <br /> DateInspection By- Dateection By �Ai &Received By January 31 ❑ July 1 &Received 8y July 31 <br /> PER SITE ❑ EACH X January REMIT <br /> PER UNIT s CHECKED <br /> Ue: ❑ ANNUALLY REMITTANCE $ AMOUNT DUE <br /> BILLING REMITTED AMOUNT <br /> BASE EXPLANATION DATE DATE <br /> C, FEE <br /> LESS ._ <br /> �. PRORATION <br /> PLUS <br /> PENALTY F <br /> OTHER ~ <br /> OTHER <br /> Date Receipt No. <br /> Permit No uance ate Mai4ed Ae+ivered <br /> Received 6y 1641 E.HAZELTON AVE P.O.Box 200`3 STOCKTON,CA952 <br /> APPLICANT—RETURN ALL COPIES 70: cNYIRONMENTAL HEALTH PERMITI5ERYICES - <br />