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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION (for Non-Transferable, Revocable, Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH-PERMIT QUALITY a ~I (COMPLETE IN TRIPLICATE) WATER Q 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 made in compliance with S n Joaquin Cqunt Ordinance No. 1862 and the rules and regulations of the Sa Joaquin Lo I Health District. Exact Site Address 219 Taddex Rd, City/Town �c aInpO,�a• ��" Owner's Name Sea.rnh Develnr)mant Phone 369-1055 i Address 920 S. Cberokie7e LnD� City T-Qd1:Cam 4'5 740 Contractor's Name ;WnnAs It Well Drilling License# 2,9286A Business Phone 209 74$2407 Contractor's Address111944 Si-mme rborn Re____r a Galt,Emergency Phone 745-3797 Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No X TYPE OF WORK (CHECK): NEW WELL IN DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION M PUMP REPAIR❑ 1 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 t INTENDED USE TYPE OF WELL ,, ❑ INDUSTRIAL JE] CABLE T6OL` Dia. of Well Excavation 8tt DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing 8tt ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 10 _ ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 501 E] CATHODIC PROTECTION ROTARY Type of Grout n r requirements sacks Cemiiir& ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: Woods fil PUMP INSTALLATION: Contractor Woods Well ;.Drilling A4 Type of Pump Submersible H.P._ly i PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done �. DESTRUCTION OF WELL: Well Diameter Approximate Depth :o Describe Material and Procedure 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County III ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. h Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich this permit {V, 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." I will call for aGro 1 Inspectio prior to grouting and a final inspection. Signed X ��1/ _ _ Title: ntraetor Date: Sept. 1911,1984� (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY F PHASE I Application Accepted By '4 Date / u Additional Comments: _ ase II Gro inspection se 111 F,�I Inspection ,[/ I�1 Inspection By Date ld � Inspection By tom[ Qate Id 16�7 Fee is Due: ❑ ANNALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BILLING REMITTANCE $ BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE O LESS PRORATYON PLUS I ` PENALTY OTHER OTHER r _ Received by Date Receipt No. Permit No. Issuance Date7 Mailed Deiivered ..f . APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 7