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. F <br /> Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The App <br /> FOR OFFICE USE: APPLICATION <br /> n _ ;gip (For Non-Transferable,Revocable, Suspendable) wtEvi WELL yy / <br /> ENVIRONMENTAL HEALTH PERMIT19182 (� <br /> (COMPLETE IN TRIPLICATE) 49) ,30 W , A=_t,-_v6,_r1yWATER QUALITY 2-3t w­al <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct-ftand/or install the work hereiSA1gcri k}�ii Np MALs <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin L AtAPNDDt8TRICT <br /> Exact Site Address Corner of Eleventh 31n & Kasson' Roa3d -_ City/Town Tracy <br /> Owner's Name =Joan J Br i l Phone <br /> Address 1029 yaw-sity yaw-sitcourt City Mt- Viim, CA 94040 <br /> Contractor's Name Ma lora Bros'"Drill n Liceryse#249957 Business Phone_(408) 724--1338 <br /> Contractor's Address 595 Airport Blv –W s n "- AEmergencyPhone (408) 842-3409 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes XXX No ' <br /> TYPE OF WORK (CHECK): NEW WELL® DEEPEN ❑ 'RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT,[] OTHER ❑ �PUMI INSTALLATION ❑ PUMP REPAIR❑ f ,� <br /> REPLACEMENT❑ � � {'�.Y4 <br /> DISTANCE TO,-NEAREST: Septic Tank None Sewer Lines. � Pit.. <br /> Sewage Disposal Field Cesspool/Seepage ivy <br /> Pit `~ Other <br /> Property LineSee MaJPrivate Domestic Well 501 Public Domestic' Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE480L Dia. of Well Excavation_ 24'1 - <br /> ++, <br /> [1DOMESTIC/PRIVATE ® DRILLED.. Dia. of Well Casingn. <br /> lfi"`Steel <br /> ❑ DOMESTIC/PUBLIC n`bRIVENp+ •r � Gauge of Casing {�r <br /> IRRIGATION - ❑,GRAVEL1.PACK li Depth of Grout Seal 50' <br /> ❑ CATHODIC PROTECTION M ROTARY_ (ReverSe) Type of Grout giWd & Cement;. <br /> _ C <br /> ❑ DISPOSAL ® OTHER Sand Pa3Cked Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: Maggiora Bros.N Drilling,—Inc- <br /> PUMP INSTALLATION: Contractor N_ <br /> t ( H.P. Y , <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR:] ❑ State Work Done t <br /> DESTRUCTION OF WELL: �* Well Diameter ( Approximate Depth <br /> ' Describe Material and Procedure <br /> Y <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 of the San Joaquin Local Health,District. <br /> I <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit t <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 forwhich this <br /> ` permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I I 'It r a ut Inspection prior to grouting and a final inspection. ) <br /> qra Secretary Treasurer <br /> Signed X IrlTitle: y- Date: F' b 4 1982' <br /> ` (Draw Plot Plan on Reverse Side) I <br /> FOR DEPARTMENT USE ONLY f rt <br /> PHASE I �' � ,. F � � � n Ct� 16A , <br /> Application Accepted By W t yDate <br /> Additional Comments: 1 <br /> E Phase II Grout Inspection I Phase III Final Inspection <br /> Inspection By 4 Date `{ Inspection By Date <br /> Fee Is Due:❑ ANNUALLY ❑'PER UNIT ❑ PER SITE ❑ EACH 13 January 1 &Received By January 31 ❑ July 4 &Received ByJuly 31 - If <br /> ` 3 = REMIT J <br /> BASE EXPLANATION BILLING REMITTANCE lr $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE I. 14 <br /> LESS 4 - r p ++ <br /> PRORATION - AIP <br /> PLUSi nl <br /> PENALTY °d' <br /> OTHER <br /> OTHER <br /> Ct <br /> Received by - ate Receipt No. Permit No. Issuance Date. - Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />