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Applications Will Be Processed When Submitted Properly Completed. BeSureTo SignTheApplication '-.r"FO�,tDFFICE USE: APPLICATION (For Non-Transferable, Revocable, Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY - Application is hereby made to the San Joaquin Local Health District fora 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. -9 Exact Site Address 315 EastI lith StreetTrac High Gamn1,G__l City/Town Tracy. ' Owner's Name Tracy Joint IIn' Phone $35-8000, Ext. 302 Address 315 East 11th Street • City Contractor's Name school district to complete WQI&nse# Business Phone Contractor's Address with ocan work force Emergency Phone is rict is part o Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No X eo ty wide W rk omp. TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION El DESTRUCTION❑ se —insured and WELL CHLORINATION ❑ WELL ABANDONMENT Il OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ K REPLACEMENT❑ none on f DISTANCE TO NEAREST: Septic Tank cam us Sewer Lines 200 feet Pit Privy none Sewage Disposal Field none Cesspool/Seepage Pit none Other none Property Line 400 f tPrivate Domestic We11500 f t. Public Domestic Well 1,000 feet INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing I ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal r ❑ 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 t PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter 6 feet Approximate Depth 20 feet Describe Material and Procedure fill to within two feet of to with impervious native clay soil and top with a two foot concrete n 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. i 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-iemploy any person in such manner as to become subject to workman's compensation laws of ali ornla. t 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 empi persons subject to workman's compensation laws of California." I all for a G ut Insp 'on prior to grouting and a final in¢pection. ASsistant Superintendent Date: May 14, _19$0 Signed Title: w Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASEI Application AccA Date S �O 0 Additional Com spection a 11" al Inspectionn�Inspection BDate IU& Inspection By DateI[/V�oFee Is Due: ❑ A ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 8 Received By July 31 - - REMIT _ BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE i LESS PRORATION PLUS PENALTY OTHER OTHER Received by Date Receipt No. Permit No. Issuance Date Mailed D4,yVedl APPLICANT—RETURN ALL COPIES TO:• .ENVIRONMENTAL HEALTH PERM ITISERVICES - 1601 E.HAZELTON AVE",P.O.Boa 2009 _ STO KION,CA 9