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Applications Will Be Processed When Submitted Properly Completed. r$;�T"g0_Tr 'AppncV1,01t i i Fe.R OFFICE USE: APPLICATION 1� a1980 ��,} (For Non-Transferable, Revocable,Suspend oa 1 p PMP&WELL ENVIRONMENTAL HEALTH PERMIT r (COMPLETE IN TRIPLICATE) WATER QUALITY SAN � �.i4"��11��-k r��U� Applicationishereby made tothe San JoaquinLocal Health Districtfor apermittoconstruct and/or instahl[*E�&WW rPAe'scribed.This application is made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address 33585 Koster City/Town Vernalis Owner's Name Steve LOgetti Phone d Address same City Contractor's Name I.J. Larsen Pum s Inc . License#276660 Business Phone 529-^2020 Contractor's Address 509 Tully Rd. `Modesto Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X NO TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 91 PUMP REPAIR❑ 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 ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Weil Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout �N ❑ DISPOSAL ❑ OTHER Other Information W ❑ GEOPHYSICAL Surface Seal Installed By: C PUMP INSTALLATION: Contractor I.J. Larsen Pumps, Inc. Type of Pump subm. H.P. 01 PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: 13 State Work Done 0 DESTRUCTION OF WELL: Well Diameter Approximate Depth M Describe Material and Procedure 1 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. Homeowner 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 for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." I will call for a ut Inspection pr'ar to grouting and a final inspection. Signed X Title: service Date: 3/17/80 (Draw Plot Plan on Reverse Side) ORD ARTMENT E ONLY PHASE Application Accepted By Date w3e_ Additional Comments: agpiumlihpt Inspection Phase f1 Fin4k Inspection g Inspection By Date Inspection By /I261,M 4— Date ib { rD Fee Is Dile: ❑ ANNUALLYFR NIT ❑ PER 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 FEE s . LESS PRORATION PLUS PENALTY (D OTHER OTHER Received by Date Receipt No Permit No. Issuance Date Mailed Delivered -APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95 3