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AppR ns Will Be Processed Whemitted ProperlyCompleted. Be SureToSign TheApplication. <br /> FOR OYFICE USE: FEB 5 1980 APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> �. PUMP&WELL <br /> SAN .1VAQ,,'INEkgiPflfflI­NMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) <br /> HEALTH DISTRICT WATER QUALITY <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 Ms <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 6416 E. PINE ST City/Town LODI , CA <br /> Owner's Name EDMUND PFEIFFLE Phone 368-1488 <br /> Address 6416 E. PINE ST City LODI , CA 95240 <br /> Contractor's Name SAN JOAQU I N PUMP CO. License ff 381012 Business Phone 369-8471 <br /> Contractor's Address 860 E. PINE ST LODI CA Emergency Phone 369--8471 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes XX No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION IBX PUMP REPAIR❑ <br /> REPLACEMENT❑ <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 /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal C <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout +t <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> © GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor SAN JOA UIN PUMP CO. <br /> Type of Pump DOMESTIC SUBMERSIBLE H.P, 1-1/2 HP <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. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <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 perso s subject to workman's compensation laws of California." <br /> I wi41 all f a ro insp p ' grouting and a final inspection. I <br /> i <br /> Signed X Title: OFFICE MGR SAN JOA UIN PUMbate: 1-28-80 <br /> (Draw Plot Plan on Reverse Side) { <br /> FOR DE ARTMENT USE ONLY'I <br /> PHASE I <br /> Application Accepted By Date D " <br /> Additional Comments: <br /> Phase 11 Grout Inspection Pf VIII Fin 1 Inspection _ <br /> Inspection By Date IVA Inspection By �` Date — f <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January`11 &Received By January 31 ❑ July 1 &Received By July 31 <br /> iREMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE L( Lr,� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Cfr <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />