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_ S ` Applications Will BeSe Processed When Submitted r APPLICATI � t" tc�able) OFFICE USE (For Non-Transferable, Revo t+ PUMP&WELL Y ENVIRONMENTAL HE Q.� S 9 L 'E WATER QUALI Y $Qkein described.This application is ,COMPLETE IN TRIPLICATE) saquin Local Health District. Application is hereby made to the San Joaquin Local Health Districtforapermittoconstructand/g AC am O /made in compliance with San Joaquin County Ordinance No.1862 and the rules and r�g H ��y own Address 24355 N. Elliott Rd, Exact Site Ali phone Owner's Name Crai Anderson city owner's 727-5548 C o 24211 N. Elliott Rd• 309031 Business Phone 209 Address pU & I , at L OUcense#�_ i Contractor's Name GOehrin $I Phone 177 54 N. H LK_Fc d. Emergency No w s Contractor's Address (� 1s Certificate of Workman's Compensation InnssurancpeE PE With SR CONDITION 0 DESTRUCTION❑ i NEW PUMP REPAIR❑ 1 TYPE OF WORK (CHECK): 1 WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION Pit Privy Sewer Lines REPLACEMENT❑ Other DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Sewage Disposal Field Public Domestic Well Property Line Private Domestic Well INTENDED USE TYPE OF�WELL— Dia:of'WeII Excavation 13 CABLE TOOti` ❑"INDUSTRIAL ❑ DRILLED Dia.of"Vilell Casing ❑ DOMESTIC/PRIVATE ❑ DRIVEN Gauge of Casing 1 ❑ DOMESTIC/PUBLIC ❑ GRAVEL PACK DEjith of Grout Seal i ❑ IRRIGATION ❑ ROTARY Yy-pe of Grout ❑ CATHODIC PROTECTION ❑ OTHER •_ %Other Information C) DISPOSAL Surface Seal Installed By: & on Inc . ❑ GEOPHYSICAL Contractor ' Gtn OEhrin Pum Irri an1%HP PUMP INSTALLATION. _ _ H.P. Type of Pump pub C1 State Work Done PUMP REPLACEMENT: ❑ State Work Dane Approximate Depth ( PUMP REPAIR: f Well Diameter DESTRUCTION OF WELL: I pescribe;Materia_1 and Procedure [ I hereby certify that I have prepared this:applicafion and-thaf'th ,wo�k:Will be done in accordance with San Joaquin County 1 1 certif that in the performance of the work for which this permit ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. I Home owner or licensed agent's signature'certifies the following:" YA to on is issued, I shall not employ any person in such manneras to tol become me"I certify that inthepsubjer erformance oflthe lwork foaws of r h this Contractor's hiring or sub-contracting signature certifies compensation laws of California." permit is s d, I shall employ personss'ubject=to workman's comp I will a out Inspection prior to gro►iling and a final inspection. Date: 10 24 79 } Title: B r I Signed X ~ (Draw_Plot-Plan on Reverse-Side) * t'FO DEP RTMEN USE ONLY _ q� I - — r.,w- k PHASE 1 Date I Application Accepted By Phase III Final Inspection Additional Comments: a �7 Phase fl Grout Inspection DaAe r 8y Da>ie inspection r inspection By Jul 1 &Received By July 31 Fee Is Due: ❑ ANNUALLY ❑ PER UNIT [❑ PER SITE ❑ EACH El January 1 &Received By January 31 REMIT $ AMOUNT DUE CHECKED BILLING REMITTANCE REMITTED AMOUNT BASE ExPLRNRTION DATE DATE f / i, + FEE LESS PRORATION PLUS + PENALTY OTHER f OTHER 1 '•' 1 1,G�� ailed Delivered Permit Na- 4ssu Ince Date Date Receipt Na 1601 E.HAZELTON AVE.,P.O.Box 2009 Received by STOCKTON.CA 95201 I - � APPLIGANT.�RETURN•AlL-COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES .