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ApplicationsWill Be Processed When Submitted Properly Completed. RF7diQA I tion. <br /> OFI9CE USE:. APPLICATIQ Cn(�l�(forNon Transferable; Revocable, ble) <br /> ENVIRONMENTAL- HEALTF{ Mimi <br /> PUMP&WELL <br /> f (COMPLETE IN TRIPLICATE) WATER QUALITY f l�1. <br /> Application is hereby made to the San Joaquin Local Health District for apermit toconstruct and/QnsfrreCh�i {Iescribed.This applications I <br /> ,- made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regula L Aa1W$T1 I olcal Health District. <br /> Exact Site Address 12905 N. Hibbard Rd. Ity/Town <br /> b <br /> j er Owner's Name Ben WePhone <br /> Address . 12905 N. .-Hibbard Rd. City <br /> Contractor's Nam6GOehrina Pump & Irric{atiOnLicense# 309031 Business Phone 727-5548 <br /> Contractor's Address 177,54 N H 88 LO kefOYCserg�jncy Phone <br /> Is Certificate of Workman's Co pensat onjlnsurance on i�e ith JLHD � fes No a <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION© DESTRUCTION❑ T <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENTZ <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 "TTYPE OF WELL <br /> ❑ INDUSTRIAL ., . ; ❑ CABLE TOOL Dia. of-Well Excavation=t T #; <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing r <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL.-- - ;: ,, _ TM --Surface-Seal Installed By.: _ <br /> PUMP INSTALLATION: Contractor <br /> I * Type of Pump- _�.� .�.. _.-- - ,, _.. - -H.P ' <br /> PUMP REPLACEMENT: tate Work Done replaced 1HP Sub With 1HP Sub_ <br /> PUMP REPAIR: ❑ State Work Done -►� <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth d <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 /> 1 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 <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 sub-contracting signature certifies the following:"I certify that in the perforfmance of the work for which this <br /> permit i hall employ persons subject to workman's compensation laws of Califorriia." <br /> I will C I r u sp4ction prior..to grouting and a final inspection. r- <br /> Signed X Title: Bkpr.. '' Dale: 06/15/82 <br /> (Draw Plot PI <br /> on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection as II Final Inspection <br /> Inspection By—A. <br /> y Date Inspection By Date <br /> I <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By`January 31 ❑ July 1-&Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> :BASE EXPLANATION DATE DATE REMITTED ,AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE [.S/V/ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No, Issuance Date Mailed Delivered <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTONAYE.,P.O.Boy 2pp9 STOCKTON,CA 95201 <br />