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Applications Will Be Processed When Submitted Properly Complet� $iiFe`ToSfgr4`'th A plictrj 7 1141 I FOR OFFICE USE: APPLICATION p hlAR 11 1989 IV /U A 1) (For Non-Transferable, Revocable Sus endable PUMP&WEL �fJ' ENVIRONMENTAL HEALTH PER IT AN J"LOAQUIN LOCAL (COMPLETE IN TRIPLICATE) 0.1 'CCJCI�IJ � EO TE UALITY C�('7 pY� .- x"." HEALTH DDlSTF! T Application is hereby made to the SanJoagtiinLocalHeIthDistricfforaper lttoconstructand/orinstaHtheworkhereinescribed.Thisapplicationis made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joauin Local Health District. Ilact Site Address 3/ mi East Hwy 99; }mil South Woadbridg�;ry/Town �odi ers N �teve MPT)OS Phone d` E. rchar Acam o city. .F_ g31,� 6 Contractor's Name L ense# 377923 Business Phone 1 Contractor's Address P. o. Box kU 61+ Emergency Phone I Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITIONJO DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ 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 141Y G ❑ INDUSTRIAL IN CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing c9 91 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information f ' ❑ GEOPHYSICAL Surface Seal Installed By: Q PUMP INSTALLATION: Contractor samisQ Type of Pump H.P. A PUMP REPLACEMENT: SD State Work Donereplace exsisting 15HP puMp With new 1, HP PUMT 0 PUMP REPAIR: El State Work Done LX�; DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure t4 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County I 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 of the worlt 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 permit is issued, I shall employ persons subject to workman's compensation laws of California." I will call for a r I pection prior to grouting and a final inspection. r Signed X -- Title:. -. Pr.ec;fde t Date: 3z3/80 (Draw Plot Plan on Reverse Side) F RD ARTME T USE ONLY PHASE ga Application Accepted By Date �l Additional Comments: u Phase 11 Grout Inspection Phas II f=inal In ection p Inspection By Date Inspection By G✓ ate G C� Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BILLING REMITTANCE $ BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER 11 U 3 0 lr Received by I Date Receipt No. Permit N6. Issu nce D to Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009' STOCKTON,C 9 J.