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Applications Will Be.Processed When Submitted Property Completed:Be Sure To Sign The Application. Fo��%c�iCE-USE: ;. » v APPLICA I '' - _ -- a {for Non-Transfer e; andle) i. . & . 1 PUMP&WELL - ENVIRONME L EALTH PERI�I,(T I (COMPLETE IN-TRIPLICATE) W QV ��J 1 J Application is hereby made to the San Joaquin Local Health District fora permit to construct and/o IMNIhe work herein described.This application is J made in compliance with San Joaquin County Ordinance No. 1862 and the rul s a lI�4`I�n f�tl�e San Joaquin Local Health District. Exact Site Address 7057. 1+ Fine Road SAS 4i RN own linden, Cs cif. enr t Owner's Name HY T MB�Z7.9T `"� -. � Phone Address 7057. N. Fine Road City tinden, Calif. Contractor's Name. PLlrVi&I1C® Drillers Drit1 inn License# 377923 Business Phone 93'�-4468 M , T-indera, Cg'f lf. 95Z36Emergency Phone Contractor's Address P. QX 64 931-4468 r Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No TYPE OF WORK (CHECK): NEW WELL IX DEEPEN ❑ 'RECONDITION❑ DESTRUCTION❑ 'C WELL,CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONM PUMP REPAIR❑ i REPLACEMENT[] r. DISTANCE TO NEAREST: Septic Tank 501 Sewer Lines Pit Privy Sewage Disposal Field ?flot Cesspool/Seepage Pit Other �+- Iv I Publlc omesticWetl f INTENDED-USE ,'TYPE OF.WELL ❑ IN©6STRIAL ® CABLE TOOL Dia of Well Excavation 811 N; ❑ DOMESTIC/PRIVFATE- ❑ DRILLED Dia. of Well Casing 11 ❑ DQMESTIC/PUBLIC []-DRIVEN Gauge of Casing 3/16n ® IRRIGATiON ❑ GRAVEL PACK OMpth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ,;- ❑ DISPOSAL ❑'OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: w_ L PUMP INSTALLATION:- Contractor Furyience Dri11 erB Drilligg Corp. Type of Pump Submersibi a H.P. 10 --- :- c. PUMP REPLACEMENT: ;mrT _ ❑ State Work Donet PUMP REPAIR: ❑ State Work Done �7 r DESTRUCTION OF WELL: Well Diameter - Approximate Depth ^ k Describe Material and Procedure , - - _ l i I hereby certify that ! have prepared this application.and that the work will be done in accordance with San Joaquin County R !s ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. t i Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit s 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 y permit is issued, I shall employ persons subject to workman's compensation laws,of California." -y,. . --- 1 I will call for a Gr inspection prior to'grouting and a final inspection. - t Signed X Title: -Pres. Date: T.?I1.5I79- (Draw Plot Pian on Reverse Side) I ZFOLDEPARTMENT USE ONLY PHASE Application Accepted By. Date Additional Comments: J - Phase 11 Grout Inspecilon Ph a III Final Inspection Inspection By DateInspection By Date ' w. c Fee is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 i I; REMIT , BILLING REMITTANCE $ .� i BASE EXPLANRTION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEELESS RORATION PLUS_._....—__ - rSF PENALTY` r OTHER u "OTHER Received by 115ate I Receipt No. Permit No. Issuance Date Mailed Delivered ? ` APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMITYSERVICES - 1601 E.HAZELTON AVE.,P.O.Sox'2009 STOCKTON,CA 95201 �`