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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION ..�' (For Non-Transferable,'Revocable,Suspendable) PUMP&WELL- ENVIRONMENTAL HEALTH PERMIT ATER.QUALITY r rte..i., ,.:. {COMPLETE IN TRIPLICATE) 1�� T Application is hereby made to the an Joaquin Local althDistrictOrapermittoconstructand/orinstalltheworkhereindescribed.Thisapplicationis made in compliance with San Joaquin County Ordi e�o. 1862 and the rules and regulations of the San Joaquin Local 1Healt Dis ri� Exact Site Address 7400 S ,�9'' Dicks S Corner City/Town ��- tin's.A t�,o ps y3 Owner's Name ' � ' �-� �' / Phone 948-8334 City Ad d ress 15 Weat-6th Street Contractor's Name License# 26 Business Phone 931-3210 . t, 1 Contractor's Address 74 70 G3ilc�ox Rd" Emergency Phone' 9 Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes X No TYPE OF WORK (CHECK): NEW WELL RX DEEPEN RECONDITION❑ -DESTRUCTION❑ WELL CHLORINATION.❑ WELL ABANDONMENT OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ f REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines - Pit Privy t Sewage.Disposal Field Cesspool/Seepage Pit Other t �, t . - ��, 5 Property_Line ' Private Dornestic'Weli - Public Dome tic Well INTENDED USE S TYRE OF WELL, �y k ,:�-k 1211 ; ❑ INDUSTRIAL f . ❑ CABLE TOOL` Dia.%of Well Excavation 6 rt ElDOMESTIC/PRIVATE /'' ❑ DRILLED Dia- of Well Casing DOMESTIC/PUBLIC w 5&CE1 DRIVEN Gauge of Casing i ❑ GRAVEL PACK Depth of Grout Seal + ❑ IRRIGATION- � } ❑ CATHODIC PROTECTION 15CROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Moorman T S WaterStems Type of Pump PUMP REPLACEMENT: ❑ State Work Done_ 9—tleF" PUMP REPAIR: ❑ State Work Done }— DESTRUCTION OF WELtx Well Diameter `� y �- Ap roxi to Depth r Describe Material and Procedure I hereby certify that I have prepared this application and that the'work wi]T'be d"one'in`accorda'nce with'San Joaquin County ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following:"I certify that in the performance o!the work forwhich this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this s" permit is issued, I shall employ persons subject to workman's compensation laws of California." I will or Gr 1 s tion prior to grouting and a final inspection.' t, Signed X , Tr T _ : 12--7-82 Title: Date y + (Draw Plot Plan on Revetse Side) ------------------------- # FOR DEPARTMENT.USE ONLY S t " PHASE i �� Dater Application Accepted By 3 Additional,Comments: f as 11 Grout spection /. Ph se III Final nspection Inspection By ate ,— f� Inspection Byd�l/ Date. 1� r I III By Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑fJanuaty'1 &Received January 31 ❑ July 1 &Received EMITuIy 31 - r.,3 BASE - EXPLANATION BILLINGS ..REMITTANCE Y AMOUNT DUE # CHFCKED [; DATE ' REMITTED' € AMOUNT 3 i s DATE l _'•, �. -. �} AM a02ti �FEE PRORATION _ .--.4..�•'mss..« ...? L»r .. +-.r...•�.•r:�r� _r..._s+�! PENALTY i OTHER —.OTHER...-,.•3. Received by Date - Receipt No Permit No. - - -- Issua ce ate Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201