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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION " i, (For Non-Transferable, Revocable, Suspendable) -PUMP&WELL ENVIRONMENTAL,HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Appl ication is hereby Made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made in aompliance'With San-Joaquin County Ordinance No.1852 and the rules and regulations of the San Joaquin Local Health District, 1 Exact Site Address 180$4` VOn Glalan City/Town E3Calon Owner's Name Allen Holmes Phone 239--2665 Address 10362 E. Louise City Manteca Contractor's Name I.J. Larsen Pum s Inc. License #276660 Business Phone 529-2020 Contractor's Address Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No TYPE OF WORK (CHECK): NEW WELL 1:1 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ I WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR C1 " REPLACEMENTRI 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 �I DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ 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 submersible H.P. 374 Type of Pump i PUMP REPLACEMENT: - ZI State Work Done Pull Old pump and install sub. l PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure i 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 II for rout Inspection prior to grouting and a final inspection. Signed X 2 Title: service Date: 9/14/79 + (Draw Plot Plan on Reverse Side) F7OR pEPART ENT USE ONLY PHASEI Application Accepted By Date Additional Comments: Phase It Grout inspection / Ph e I Final I pection Inspection By Date N Inspection By ate Fee Is Due: ❑ ANNUALLY ❑ PER UNIT El SITE © EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceVJu REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED �? AMOUNT FEE r L� f LESS PRORATION PLUS PENALTY OTHER ' OTHER � © �t w '77 Received byate Receipt No. Permit No. Issuance Date Mailed De$ivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601-E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201•