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1,}'ptfca� 1Nilk ie Orbjessci h ' Submitted ProgenyLomplecea. Oe ""z ,REA y rR _ N TI <br /> rOR OFFICE USE: l ' 1 APPLICATION <br /> (For ransierable, Revocable, Suspendable) <br /> I MAY 13 198�ENVIRONMENTAL HEALTH PERMIT <br /> COMPLETE IN TRIPLICA s I IISp WATER QUALITY <br /> Application is-herebyTRIPLade fl q 1}€ 1 Districtforapermittoconstructand/orinstallihework herein described.This application is <br /> made in compliance with San J m�u y�64� rnce No.1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 8679 B�__Kettl_e_man Ln- City/Town <br /> Owner's Name Charles smj&ymx Seiler Phone <br /> Address 8679 E. Kettleman Ln, City--- <br /> 5548 <br /> Contractor's Name G�hring P 1_� & lrrlgatio73cense# 309031 Business Phone 727--554$ <br /> Contractor's Address _-_ Emergency Phone 17754 N. H . 88 L7kfd. <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❑ AA <br /> WELL CHLORINATION El WELL ABANDONMENT E] OTHER El PUMP INSTALLATIONS PUMP REPAIR . <br /> REPLACEMENT❑ � <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit OtherVi <br /> Prroperty Line Private Domestic Well Public Domestic Well <br /> '• TYPE OF WELL <br /> INTENDED USE D <br /> 11 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 <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ElDISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION:This is bo&kUactor Goehrina Pump-•&- Irrigation nC V. <br /> agricultural & domes 1C Ty�of Pump subtler .bl- H.P. 71- <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP'R£PAtf i` 0 $tate inldrk Uane�= _.. <br /> DESTRUCTION OF WELL: We11 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 /> }come owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich this permit <br /> is issued, I shall not e.�mploy any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring Sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is is all employ persons subject to workman's compensation laws of California." <br /> I will cal I u spection prior to grouting and a final inspection. <br /> Signed X Title: Bk Date: 05/3.3/$1 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY l <br /> PHASE 19 1 <br /> Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phase It Grout Inspection ctionInspection By DateInspection B/�P�haqe �! <br /> ate }Gl <br /> Fee Is Due: ❑ ANNUALLY f ❑ PER UNIT ❑ PER SITE ElEACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <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.HAZELTON AVE.,P.O.Box 20119 STOCKTON,CA 55201 <br />