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_ -_- __ --- ENVIRONMENTAL HEALTH PERMIT PUMP&WELL (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No. 1662 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address 18084 Von Glahn ___— City/Town Escalon - . Owner's Name Allen Holmes Phone 239-2665 - - Address -- 10362 E. Louise City Manteca Contractors Name I J Larsen Pumps Inc. License#276660 Business Phone 529-2020 _ Contractor's Address Emergency PhoneIs Certificate of Workman's Compensation Insurance on File With SJLHD? Yes XNo TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION-0 DESTRUCTION❑ - WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR REPLACEMENT1r1 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 ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation— R1 xcavation R1 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing Q ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing — - ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal -- ---� ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout --- ❑ DISPOSAL ❑ OTHER Other Information —yam ❑ GEOPHYSICAL Surface Seal Installed By: __ J PUMP INSTALLATION: Contractor - � Type of Pump submersible H.P. 4 PUMP REPLACEMENT: g1 State Work Done Pull old pump and install 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 permit is issued, I shall employ persons subject to w orkman's compensation laws of California." I will"II for. rout Inspection prior to g�routtiing and a final Inspection. Signed )( e4?4L1 / oo,, — Title: . Service Date: 9/14/79 (Draw Plot Plan on Reverse Side) FO DEPART ENT USE ONLY PHASE q Application Accepted By Date / Additional Comments: ___ 0 Phase II Grout inspection / Ph I Final 1 pectionC� Inspection By Date �/ Inspection By ate / Z Fee Is Due: ❑ ANNUALLY 11PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July 1 a RIK y July 31 REMIT BASE EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED DATE DATE REMITTED ! AMOUNT FEE J v LESS PRORATION _ PLUS PENALTY OTHER OTHER q��a7T t'�Lt o'7(� _ ZG 9lo '1/ao�7y - Receipt No. Permit No. lewence Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1301 E.HAZELTON AVE.,P.O.90a 2333 STOCKTON,CA Stan - - .. yr -•