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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> 10 (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY V, <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is­� <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 1 586 W. Armstrong Rd . City/Town T,odi <br /> Harvey Pickens <br /> Owner's Name Phone <br /> Address 1586 W. ArmstronF Rd . City LLb <br /> Contractor's Name Machado, Inc . License#377040 Busine PhQne 2-1424 <br /> Contractor's Address 247 N. Jack TIone Rd. Emergency P_(ione �µ 00 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT 8 <br /> DISTANCE TO NEAREST: Septic Tank 200 Sewer Lines 200r Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line 2000 Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> 1010 <br /> ❑ INDUSTRIAL El CABLE TOOL Dia. of Well Excavation <br /> 12 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 12 <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 509 <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout Bentonite <br /> ❑ DISPOSAL ❑ OTHER _ Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: ODI aC hado _ <br /> PUMP INSTALLATION: Contractor '�11 %% <br /> Type of Pump H.P. b <br /> O' <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. 0 <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit f <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 1 will-50 for a Grout I7madAe� <br /> ction prior to routing and a final inspection. <br /> Si ned X � /y/., Sect9 Title: y Date: 1-31-80 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR EPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By '4�'� Date alb <br /> Additional Comments: <br /> ha I Grout Inspectio'ryrhase I IL F' al Inspection <br /> Inspection By *1ection By Date ` Date <br /> Fee Is Due: ❑ 1,XPER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE y ✓ <br /> LESS u <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> th�51--- 3 o.O S <br /> Received by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />