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lications Will Be ProcessePh9en Submitted Properly Completed. BesureTOSign ineAppncanon <br /> APPLICATION <br /> FOR FOR OFFICEbSE: APR 4 1980 <br /> L _ (For Non-Transferable, Revocable,Suspendable) PUMP&WE;LL <br /> AN JOAQUIN LOC ANVIRONMENTAL HEALTH PERMIT <br /> HEALTH DISTRICT WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> 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 <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 30773 Tracy Blvd. c City/Town Trac, <br /> i Owner's Name Richard Rose Phone 209s 835-1240 <br /> Address - 30773 Tracy Blvd. City Trac <br /> Contractor's Name western Well Drilling CO+License# 25182 Business Phone 4080 295-4332 <br /> Contractor's Address P.O BOX 109�. S,9n JOSe - Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> {' WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> r Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 29 IRRIGATION -Iff GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> 1 Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done W <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth t1 <br /> Describe Material and Procedure _%) <br /> v <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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <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 perso subject to workman's compensation laws of California." <br /> { I will Graut Inspection prl to outing and a final inspection. <br /> Signed Title:.- _ President Date: 4/3/80 <br /> N,,T. Bradford it (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> I <br /> I PHASE 7 <br /> Date <br /> Application Accepted By ; <br /> Additional Comments: <br /> rPhase 11 Grout Inspection Phas pection <br /> Inspection By Date Inspection By 111 1 InsDate ' <br /> Fee Is Due: 13 ANNUALLY ❑ PER UNIT El PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REM$T <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> ' FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHERJill J` <br /> / (� <br /> CSS �S L 10 <br /> Received by L" Dbite Receipt No, Permit No. lisuande Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E:HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 95201 <br />