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ApWaki6s Wlfi 1pe Processed Whe�a-'"mitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: F�b 5 1980 APPLICATION f (For Non-Transferable, Revocable, Suspendable) ' SAN .�i)r:0!_V1,,t �,l� PUMP&WELL 4 HEALTi DSS i'rii '1'6NMENTAL HEALTH PERMIT 6. (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address 25992 N. ELLIOTT ROAD City/Town GALT, CA Owner's Name JOHN TOLEDO DAIRY Phone C/o VERNE VIERRA 369-9226 Address ' 25992 N. ELLIOTT RD City GALT, CA Contractor's Name SAN JOA U I N PUMP CO. License it 381012 Business Phone 369-8471 Contractor's Address 860 E. PINE ST, LOBI_, CA Emergency Phone 369--8471 Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes XX No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONIX PUMP REPAIR REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line #;; Private Domestic Well _Public,Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION Cl ROTARY Type of Grout u ❑"DISPOSAL ES-OTHER ' —Other Information" ,t 11_GEOPHYSICAL.,,^,�Y, _ Surface Seal Installed By:.- PUMP INSTALLATION: Contractor SAN JOAQU IN PU MP CO. _ Type of Pump SUBMERGIBLE H.P. 5 HP PUMP REPLACEMENT:' ❑ State Work Done PUMP REPAIR: t I f - 11 State Work Done dNft DESTRUCTION OF.WELL: �'��"Well Diameter - Approximate Depth Describe Material and Procedure I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. IHome owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." n Contractor's hiring Or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ perso s subject to workman's compensation laws of California." I wl or a GrV Insp togroutingand a final inspection. Signed XA_ . . _ I - _ Title: OFFICE MGR, SAN JD ' _ _ PUM�tate:_ 1�-28-80 l (Draw Plot Plan on Reverse Side) 46 FOR DEPARTMENT USE ONLY PHASE I Application Accepted By i Date Additional Comments: Phase 11 Grout Inspection L1 Pf se Final In ection Inspection By Date Inspection By!+� ate Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 t BILLING REMITTANCE $ REWT BASE EXPLANATION AMOUNT DUE CHECKED x DATE DATE REMITTED AMOUNT FEE 04�L j LESS PRORATION �.. PLUS PENALTY OTHER OTHER Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1661 E.HAZELTON AVE,,P.O.Box 2069 STOCKTON,CA 95201 ' f