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Applications Will Be Processed-When-Submitted Properly Completed. Be Sure ToSign TheApplication. j FOR FFI USE: APPLICATION ' For Non-Transferable, Revocable, Suspendable) ( PUMP&WELL Qq ENVIRONMENTAL HEALTH PERMIT �. WATER QUALITY (COMPLETE IN TRIPLICATE) I Application is hereby made to the San Joaquin Local Health District for a permitto construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No. 1852 and thE'rules and regulations of the San Joaquin Local Health District. Exact Site Address nth Trac r e City/Town :t Owner's Name Tracy Joint Union High 5 hoof Phone Address 'll 5 F F1 Pyenth City Tracy Contractor's Name Western W _11 Dri11 iC19CQ_,_-Ltdense# 25182 Business Phone (408) 295-4332 "r Contractor's Address P Q, Rnx 1 D4-, Sin J0Sp_ Emergency Phone ` F Is Certificate of Workman's CompensationIns ranee on File With SJLHD? Yes No _ TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER PUMP INSTALLATION PUMP REPAIR❑ r REPLACEMENT❑ 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 ❑ DOMESTIC/PRIVATE 11 DRILLED Dia. of Well Casing 11DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal l ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout If ❑ DISPOSAL ❑ OTHER Other Information 1 ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H.P, PUMP REPLACEMENT: IJ State Work Done C PUMP REPAIR: ❑ State Work Done . DESTRUCTION OF WELL: Well Diameter and 1011 Approximate Depth 672 ' Describe Material and Procedure RPMOVe pump_., TV log of well casing, clean out I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Countgasollneg rid well of bacteria. y ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner 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.” 'II call f Inspection prior to groutin and final insp Signed X Title, e �� Date: d V (Draw PI Ian on Reverse Side) FO DEP TMENT USE ONLY PHASE 1 f Cj Application Accepted By. Date Additional Comments: t4 Phase Il Grout Inspection Pha I nal Inspection j Inspection By Date Inspection By Date 3 3— Fee Is Due: ❑ ANNUALLY' ❑ PER UNIT PER SITE 1:1 EACH ❑ January i Received By January 31 ❑ July 1 &Received By July 31 REMIT BASE EXPLANATION BkLLING REMITTANCE $ AMOUNT OUE CHECKED DATE DATE REMITTED AMOUNT FEE Few k I LESS PRORATION ` PLUS PENALTY LOTHER fw,F. - r..e- wr .w ti..yi +•w+ e. ate.g - - - i OTHER `f - ligE {J y Received by Date Receipt No. Permit Issuance Date Ma6ed Delivered 'mow � Recei APPLICANT—RETURN ALL COPIES TO: -ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.'HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 "