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;ApplicationsWill Be ProcessedWhenSubmitted Properly Completed. Be Sure To Sign The Application. FOR oF.F USE: APPLICATION (For Non-Transferable, Revocable, Suspendable) PUMP&WELL Y ENVIRONMENTAL HEALTH PERMIT n (COMPLETE IN TRIPLICATE) WATER QUALITY Application 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 rrOde in compliance with Ian Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. H Exact Site Address �r_v��,_S�ia .� _ City/Town Tracy r a.ge.. Owner's Name Don CosC _. Phone 4 Addresscity Modesto Contractor's Name .�in�i T�„a i n rl� � g License# Business Phone54 -*1 85 + Contractor's Address i'�Ellandale Ave— Emergency Phone 54�1 185 Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No oL1 TYPE OF WORK (CHECK): NEW WELLM DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ — w WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR 6 REPLACEMENT❑ ^9 DISTANCE TO NEAREST: Septic Tank 1-00 Sewer Lines Pit Privy Sewage Disposal Field 1 Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL b ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 121" __- 99 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 6" ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing PVC 160 ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal 50 8 ❑ CATHODIC PROTECTION tl ROTARY Type of Grout �-e]1ellt ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: _D5111e _CSW PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done ; PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth ; Describe Material and Procedure 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. k Home owner or licensed agent's signature certifies the following:"I certify that in the performanceof thework for which this permit I 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." C I will call for a Grout Inspection prior to grouting and a final inspection. tom' Signed X Title: Date: (Draw Plot Plan on Reverse Side) FOR D&PARTMENT USE ONLY PHASE 1 / �/`T�` Application Accepted By Date/ Additional Comments: Pha E II Orrout Inspection / Phase III Final Inspection Inspection By r Date d �`� Inspection By °��' Date Fee Is Due: ❑ ANNUALLY - ❑ PER UNIT. ❑ PER SITE ❑ EACH ❑ January 1 &Receivecl By January 31 ❑ July 1 &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED + 7� AMOUNT FEE �J LESS PRORATION PLUS PENALTY i OTHER OTHER "t Received by D fe - Receipt No. Permit No. issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 r