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Applications Will Be Processed When Submitted Properly Completedli <br /> eair gn Th Apion. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, S dable) +� 19�o MP&WELL <br /> ENVIRONMENTAL HEALTH t MIT3�� } <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY v irr5��1C'� <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/& ljt�XArkherein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations df' e San Joaq�,it�CLocdlealth District. <br /> Exact Site Address 1 .960 S, Austin Rd, City/Town ML <br /> Andy Keuning 599-3124 <br /> Owner's Name Phone <br /> Address 1 .960 So, Austin _ City Mtci Ca. <br /> Contractor's Name Bill Weibel License# 2$6086 Business Phone 23-441 <br /> Contractor's Address 1165 Main St. Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ 11, <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 0 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor A, & B. Electric <br /> rr <br /> Type of Pump /��J' H.P. <br /> PUMP REPLACEMENT: O-State Work Done_ T <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. <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit S <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 for which this <br /> permit is issued, i shall employ persons subject to workman's compensation laws of California." <br /> 1 will call for a Grout Ins tion prion to grouting and a final inspection. l <br /> Signed X - � –C>'L�G^�LEz-�--- Title: es��� Date: 7 d <br /> (Draw Plot Plan on Rev rse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By �7;6� Date -1 0 <br /> Additional Comments: - <br /> Phas IG t Inspection as III Final Inspectio <br /> Inspection By— uDate Inspection By Date vc <br /> .� <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE +!' t <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> to-4- a 3 <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 9520 <br />