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Applications Will Se Processed When Submitted Properly <br /> FOR-O�ICE USE: nn 9 PUMP&WELL' i <br /> (For Non-Transferable, Revocable, Suspendable)0 L,� 8 �78� <br /> � . <br /> ENVIRONMENTAL HEALTH PER{�1 I <br /> S �Crr�.eL.00"AL <br /> WATER QUALITY HEALTH I �§J�Igj dbed.This application is <br /> (COMPLETE IN TRIPLICATE) <br /> Ordinance No.1862 and the rules and regulations <br /> Application DisApplication is hereby made to the San Joaquin lLocal Health District for a permitto construct and/or install t e wor <br /> tions of the San Joaquin Local <br /> made in compliance with San Joaquin County City/Town ___Ace Po, <br /> �4Q244_- Wer�Sa_ amentD Rom <br /> Exact Site Address Phone 22 <br /> Jahant Ranch city Ac <br /> Owner's Name P.O. Box 2 5 369-8471 <br /> Address License# 381, 012 Business Phone <br /> SAN JOA DIN PUMP CO. Same <br /> Contractor's Name Lodi CB Emergency Phone d <br /> 860 E. Pine St. ? Yes X� No —�- <br /> Contractor's Address <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD. <br /> RECOND <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ OTHER ❑ ITIOP❑P INSTALLATION ❑ PUM <br /> ABANDONMENT P DESTRUCTION REPAIR❑ <br /> WELL CHLORINATION ❑ WELL <br /> 1 <br /> I T` Pit Privy <br /> REPLACEMEN , <br /> Sewer tines Other <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit <br /> Sewage Disposal Field Public Domestic Well <br /> E Property Line <br /> Private Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ CABLE TOOL Dia. Of Well Excavation 1 <br /> C] INDUSTRIAL 13 DRILLED Dia. of Well Casing <br /> ElDOMESTIC/PRIVATE El DRIVEN Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC [I GRAVEL PACK Depth of Grout Seal <br /> C1 IRRIGATION 13 ROTARY Type of Grout <br /> C) CATHODIC PROTECTION ❑ OTHER Other Information <br /> [I DISPOSAL Surface Seal Installed By: <br /> ❑ GEOPHYSICAL Contractor <br /> H.P. <br /> PUMP INSTALLATION: Type of Pump <br /> t CI State Work Done Re lace exi sti n um with 3 HP submer `i b e um30 <br /> PUMP REPLACEMENT: E3 State Work Done approximate Depth <br /> j PUMP REPAIR: l� Well Diameter <br /> t DESTRUCTION OF WELL: <br /> I Describe Material and Procedure <br /> —' - re <br /> pared this applicati f the San Joaquin work willHeaI Districtbe done in ccordance with San Joaquin County <br /> 6 I hereby certify that I have p P <br /> _ ordinances, state laws, and rules and regulations og <br /> ch <br /> r manner as to become subiect to workman's compensation laws of California." <br /> Home owner or licensed agent's signature certchesrthe following: I certify that in the performance of thewor h°wor i for allifor this <br /> is issued, I shall not employ any Person in such <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance o <br /> permit is issued, I shall employ persons subject to workman's compensation laws Of California." <br /> e on-prior to grouting and a final inspection. <br /> Call four a G a ,} I P MPDate: 3 OCT 80 <br /> j Title: <br /> R <br /> Signed X �.� (Draw Plot Plan on Reverse Side) <br /> 1 FOR DEPARTMENT USE ONLY eo <br /> 7Date--- <br /> PHASEI <br /> Application Accepted By <br /> Additional Comments: P ha a III Final InspectPhase I1 Grout Inspection Dat <br /> Inspection By <br /> r Date <br /> I inspection By ❑ July 1 &Received By Su1Y 31 <br /> r ❑ January t &Received By Sanuary 31 REMIT <br /> r Fee Is Due: ❑ ANNUALLY ❑ PER UN'T ❑ PER SITE ❑ EACH $ AMOUNT DUE CHECKED <br /> BILLING REMITTANCE REMITTED AMOUNT <br /> BASE EXPLANATION DATE DATE <br /> FEE <br /> LESS �+ <br /> pRORAT%ON— - <br /> PLUS x <br /> PENALTY - <br /> OTHER <br /> OTHER <br /> Delivered ' <br /> F _ Permit No Issuance'Date <br /> Date Receipt No. - 1501 E.HAYELTON AYE.,P.O.aoK 2009STOCI(TON,CA 45261" <br /> t Received by ` - <br /> APPLICANT—RETURN ALL.COPIES TO: ENVIRONMENTAL HEALTH PERINIT/SERVICES <br />