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Applications Will Be Processed When Sudmilted Properly Completed.BeSureTo5 eA FOR OFFICE USE: APPLICATION 771 J. >>r (For Non-Transferable, Revocable, Suspendable) PUMP& ENVIRONMENTAL HEALTH PERMIT 17 1979 (COMPLETE IN TRIPLICATE) WATER QUALITY r r Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or installt&"rk1@r0 rit L7 application is h made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the S412cAjqq5f�"Jt tis}rict. Exact Site Address 2nd house on North side of Hogan East Off HWY�9/Town [� L , Owner's Name JIM SUMMERS Phone 369-5696 Address 4893 E. H GAN LN City LODI Contractor's Name SAN JOA UIN PUMP CO. License# 381012 Business Phone 369-8471 Contractor's Address 860 E. PINE ST, LODI, CA Emergency Phone 369-8471 Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes XX No �S TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR �I REPLACEMENT❑ 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 y ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation — p1 J{ ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia.,of Well Casing ❑ DOMESTIC/PUBLIC -0-6-RIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL-PACK Depth of Grout Seal ❑ CATHODIC PROTECTION... y ❑ ROTARY' _ Type of Grout ❑ DISPOSAL r ❑ OTHER Other Information 11 GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump- H.P. I PUMP-REPLACEMENT: ❑ State Work,Done PUMP REPAIR: 9(State Work Done Pill L 1 HP DOMESTIC SUB PUMP CHECK FOR ELECTRICAL PROBLEM' DESTRUCTION OF WELL: Well Diameter` '` Approximate Depth Describe Material and Procedure -. i 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 workman's compensation laws of California." I will al r a Gr . frtsp tFo rior 10 grouting and a final inspection. Signed7X (/ Title: _ OFFICE MGR Date: 15 OCT 1979 (Draw Plot Plan on Reverse Side) FORD PARTMEN USE ONLY ` PHASE I 1., �,_ y�7q Application Accepted By Date Additional Comments: Phase 11 Grout Inspection Ph a III Final lnspecl on Inspection By Date Inspection Bye ate' Fee Is Due:-❑ ANNUALLY ❑ PER UNIT 1XPER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BASE EXPLANATION BILLING - REMITTANCE $ AMOUNT DUE CHECKED - DATE DATE REMITTED AMOUNT I I FEE - LESS , PRORATION - =� PLUS PENALTY OTHER .. F OTHER )0// 7 ?7z %ls7,''7`I Received by ate Receipt No. Permit Na Issuance Date Mailed Delivered APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201