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APplc �IlxwI1k3eProcesnd When Submitted Properly Comp E6'S?rre'Ho SignfheL6i t n. �i r t FO OFFICE USE: *' l �g� APPLICATIQN Y _ A� E \, k A. 1 P� (For Nip ransferable, Revocable,SuspendabO N 2 1 1981 �Y JPUMP&WELL [� E� 510NMENTAL HEALTH P T � WATER QUALITY �� JD ,QUIN LOrAL {COMPLETE IN TRIPLICATE) A �j HEALTH DIST�I�T O�3 " Application is hereby made to the%,r 61 n Local Health District for a permit to construct and/or install the work herein described.This application is made in compliance.with_San..J.oaquin-County_Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address IOi&S�OODB-'; DG E-. 4 City/Town Owner's Name —WOnnRRTDGF G, IF R COI -NTRY N 11R. Phone 3 Address — WOOD RIDGE ROAD city WOOIlBRI_DGE, CA 95 58 r--- Contractor's Name NOACK PUMPS License# 35591:3 Business Phone 948-$81] t ` Contractor's Address45f)O--E FRF[vONT—Sli_ S LKIOEmergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes - No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN E] RECONDITION E] DESTRUCTION❑ WELL CHLORI ION 11 WELL WELL ABANDONMENT OTHER PUMP INSTALLATION PUMP REPAIR ( REPLACEMENTS 4- DISTANCE DISTANCE TO NEAREST: Se} t :f. 4 - ,. �i �SSewer LineitSc Pit Privy 5gwage-Disposal Field A # Cesspool/Seepage Pit x Other .,..5,,,.,,.Propertp Line -r Private Domestic Well Public Domestic Well ti INTENDED USE TYPE OF WELL F ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal t ❑_CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information y ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Q ;I Type of Pump H.P. PUMP REPLACEMENT: ;- x i4 )CATState-Work Done�R . .'. �&�RER LACE=WITN $-I��. . PUMP.REP.A4R: -- .. `s__ ! ❑ State-1Nork-Done DESTRUCTION OF WELL: Well [Diameter ! + Approximate Depth � Describe Material and Procedure 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 folio I certify that in the performance r g:` Y p of the work forwhichthis permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." a` 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 call for a Grout Inspection prior to grouting and a final inspection. "SignedX JOE BORGES Title: Date:SERVICE MANAGER 19 JAN 19$1 (Draw Plot Pian on Reverse Side) r� F RDE ARTMEN7 USE ONLY t PHASE r/ 3 t I5 Application Accepted By W4t p Additional Comments: Date a�7 a .. - Phase Il Grout Inspection Phase I Final Inspection Inspection By Date s Inspection By Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 LSI ,1'uly 1 &Received By July 31 REMIT BASE EXPLANATION BILLING R-"D T E $ AMOUNT DUE CHECKED t ' DATE "`DATE REMITTED { FEE AMOUNT LESS ` ',PRORATION PLUS e 'y PENALTY ATHER THER `eivetl by Date Receipt No - Permit No. Issuance Date- Mailed - Delivered r %PPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES - .1601 E.HAZELTON AVE.,P.O.Box 2009 _STOCKTON,CA 95201