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li <br />FOR DEPARTMENT USE ONLY <br />PHASE I <br />Application Accepted By <br />Additional Comments: _.12.415 -60 <br />Phase 11 Grout inpecWon <br />Date Inspection By <br />/ <br /> <br />D. ii •,. <br /> <br />4\ _1„7,6 <br />Phase NI Anal Inspection <br />inspection By Date <br />1..Iy 1 8. Pece ved By J_'y 31 <br />REM 17 <br />C,:tiECKED <br />AMOUNT <br />0 Pee siiE 0 VACM 0 Jart,.;,,y 1 $ Receive° By Jan,sary 31 <br />BILLING' I REMITTANCE EXPLANATION DATE I LIA`E BASE HEMITTFI) <br />Fee Is Due: 0 ANNUAL! <br />1601 E. HAZELTON AVE., P.O. Box 2005 STOCKTON, CA 95201 APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT:SEFIVICES <br />FE+ <br />LESS PROR A T.ON <br />PLUS PENALTY <br />°MU; <br />- <br />k.;THEFI <br />Te <br />0 PEW UNIT <br /> Si .75_ —7 ssuance Date Mailed Delive,ed Roce:pt 1\1/.1 Perrtil Received by <br />ENVIRONMENTAL H <br />I;L •Ipetrambie) <br />r \ ,,t,i <br />A <br />APPLICA <br />(For Non-Transferable. Re <br />. .1 OFFICE USE: 1 <br />TH PERMIT ,(179 <br /> <br />NO \I a t '-'` <br />(COMPLETE (N TRIPLICATE) WATER QUALITY <br />Applrcation is hereby made to the San Joaquin Local Health District for a permit to construct ariVr(c0,4triti orAerein described. This application is <br />made in compliance with San JoaLlin Count rdinance No. 1862 and the rules ar6 )°1-/IST <br />cal Health District. <br />Exact Site Address I/ .3, <ii...\_ l_i -Altk-- <br />}A L ulatl ' <br />ay/Town <br />..0°P Phone 4.1 6. L-12./ <br /> City <br />- <br /> <br />City ._iL—ILZ <br />PUMP REPAIR rir" <br />Other <br />ra <br />Contractor _ <br />Well Diameter <br />Describe Material and Procedure <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br />ordinances, state laws, and rules and regulations ol the San Joaquin Local Health District. <br />Home owner or licensed agent's signature certifies the following: certify that in the performance of the work tor which this permit <br />is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br />Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this <br />permit is issued, I shall employ persons subject to workman s compensation laws of California: <br />Signed <br />wii II for a Grout ection prior to • outing and a final inspection. • <br />X Title: <br />(Diawtef(rPlan on Revert Side) <br /> <br /> Date L//27 <br /> <br />PUMP & WELL <br />Owners Name <br />Address __el__(•e -&-141-49"r‘ <br />Contractor's Name <.V License #143 3_ Business Phone <br />Contractor's Address 4 KA Emergency Phone 641,‘,._L_' <br />Is Certificate of Workmaris Compensation insurance on File With SJLHD? Yes No <br />TYPE OF WORK rCHECK): NEW WELL 0 DEEPEN 0 RECONDITION 0 DESTRUCTION 0 <br />%NELL CHLORINATION 0 WELL ABANDONMENT OTHER 0 PUMP INSTALLATION 0 <br />REPLACEMENT 0 <br />DISTANCE TO NEAREST: Septic Tank _ Sewer Lines Pit Privy <br />Sewage Disposal Cesspool/Seepage Pit <br />Property Line Private Domestic Well Public Domestic Well <br />INTENDED USE <br />o INDUSI-RIAL <br />DOMESTIC/PRIVATE <br />DOMESTIC/PUBLIC <br />IRRIGATION <br />CATHODIC PROTECTION <br />ID DISPOSAL <br />GEOPHYSICAL <br />PUMP INSTALLATION: <br />PUMP REPLACEMENT: <br />PUMP REPAIR. <br />DESTRUCTION OF WELL: <br />TYPE OF WELL <br />CABLE TOOL <br />DRILLED <br />DRIVEN <br />10 GRAVEL PACK <br />ROTARY <br />OTHER _ <br />Type of Pump HP <br />State Work Done <br />[tate Work Done Pi e <br />Approximate (Depth <br />Dia. of Well Excavation <br />Dia. of Well Casing <br />Gauge of Casing <br />Depth of Grout Seal <br />Type of Grout <br />Other Information <br />So face Seal Installe