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A tions Will BWhen Submitted Properly Completed. Be Sure To Sign The Application. FO# OFFICE,USE: 1AM J of IBt APPLICATION x -� T"N6LTransierable, Revocable, Suspendable) SNE �>< P� H SdIR TIONMENTAL HEALTH PERMIT PUMP&WELL (COMPLETE IN TRIPLICATE) H WATER QUALITY Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.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 City/Town 100T _ CA Owner's Name WALI-F-QURNIE Phone - __ 369-7323 Address 3900 SCOTTSDAI RD City 100T , CA ' Contractor's Name SAN JOAQUIN PUMP CO. License# Business Phone 369-8471 Contractor's Address 860 E. RINE_ST-1—L9DI Emergency Phone SAME C Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes XX No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRKX REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other rr Property Line Private Domestic Well Public Domestic Well 1 INTENDED USE TYPE OF WELL .�❑,/INDUSTRIAL 11 CABLE TOOL Dia. of Well Excavation DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing X IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: 0 State Work 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 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 forwhich this permit is issued, I shall employ persons subject to workman's compensation laws of California." I a Grout 1 �c�-pri to gro ting and a final inspection. Signed X �YT�R Title: _ OFF_ICE_MGR Date: 13 MAY 1980 (Draw Plot Plan on Reverse Side) FORD PART ENT USE ONLY PHASE I 1 ,l Application Accepted By 2 Date Additional Comments: Phase II Grout inspectionPha Final In ectio inspection By Date Inspection By Dated "u Fee Is Due: ❑ ANNUALLY ❑ PER UNIT I] PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 t REMIT BILLING REMITTANCE $ BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE /RREEMITTED AMOUNT FEE ( / LESS PRORATION PLUS PENALTY OTHER 0000 OTHER 6 I S 'y 6 3 �� S'3 Received by jDate Receipt No. Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 96201