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ApplicationsWill BeProcessedWhen Submitted Properly CompleIftr64oL9gI TIf A��jj ��llic FOR OFFICE USE: APPLICATION �9 (For Non-Transferable, Revocable, SuspendablQ r 3 79 VP&WELL � ENVIRONMENTAL HEALTH P T (COMPLETE IN TRIPLICATE)NOrk • 3PZ,& NWOER'UALIT ��QUIJIj L��,Applicationishereby made tothe San JoaquinLocal HealthDoraprrml�to"tonstMtand/or instal ewr Wl tkscnbed.ThisapplicationI�,iC made in compliance with San J aquin County Ordinanc o. 1862 and the rules and regulations of the San Joaquin Local Health District, Exact Site Address �I /rl �'v-rr-1 . .2� d JJ/ SJ`o City/Town Owner's Name Dick Pires Phone 835--2553 ;Address P. 0. Box 265 City Vernalis Contractor's Name I .J. Larsen Pumps, Inc. License#276660 Business Phone 529--2020 Contractor's Address 509 Tully Road Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ --WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 13 REPLACEMENT® DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy l 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 ❑ ROTARY Type of Grout C— ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor " Type of Pump H.P. PUMP.REPLACEMENT:' :0 State Work Done Pull 3 h.p. replace with 2 Ia.-p. sub PUMP REPAIR: ❑ State Work Done 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. Home 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." Contractor's hiring or sub-contracting signature certifies the following:"I.certify that in the performance of the work forwhich this i permit is issued, I shall employ persons subject to workman's compensation laws of California." I for a Gr spection prior to grouting and a final inspection. Signed X Title: serviceDate: 10/26/79 (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE Is Application Accepted By Date Additional Comments: Phase II Grout inspection Phase III Final Inspection Inspection By Date Inspection By _ Date r 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 EXPLANATFON ! - AMOUNT DUE CHECKED DATE DATE REMITTEDPA AMOUNT iY ✓ I FEE I LESS PRORATION V PLUS PENALTY OTHER OTHER -79_.�4 v� ~ I1&11-7 ai Received by Date Receipt No Permit No Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: -ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9