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bpn, `property Completed.Be> igOtThAW AppueanGM D / <br /> Applications Will TIO Nyyy , <br /> FOR O FICE USE: l , ocable,Suspendab a VAR. 5 PL71VtP&WELL <br /> ` (For Non-Transte <br /> APAApp NT EALTH PERMIT SAN .1C! QLtI` LOCAL <br /> WATER QUALITY ki TUipb§$TN�T <br /> (COMPLETE IN TRIPLICATE) $A�,i Ji:��,(�r ar t , 1 s I .This application is <br /> Application is hereby made to the San JoaquiNegt ea hrI` r f ermittoconstructand/orinstallt <br /> made in compliance with San Joaquin County OrdinanceW JK?t�e rules and regulations of the San Joaquin Local Health District. <br /> City/Town Tracy. <br /> Exact Site Address 25 14 Hard 209/836-0005 <br /> C & A Navarra Ranch, -Inc. Phone CA 6 <br /> Owner's Name W. Blewett Road City Trac <br /> Address 7 Ltd 2 182 � Business Phone 4Q8 29 -4 32 <br /> Contractor's Name Western well Drillin CO•s License# 5 <br /> Contractor's Address r O• BOX 1(M. San Jose CA QS103 Emergency Phone <br /> No <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes 1 <br /> DESTRUCTION❑ PUMP REPAIR® <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION I2 1 <br /> WELL CHLORINATION 13 WELL ABANDONMENT C1 OTHER ❑ PUMP INSTALLATION❑ <br /> REPLACEMENT❑ Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other <br /> Sewage Disposal Field Public Domestic Well <br /> Property Line Private Domestic Well, <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL - ® CABLE TOOL., <br /> Dia. of Weil Excavation a <br /> 13 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing :1411 <br /> ❑ DRIVEN Gauge of Casing 1�Olible l0 i32Li6Lt3 <br /> ❑ DOMESTICIPUBLIC Depth of Grout Seal <br /> IN IRRIGATION ❑ GRAVEL PACK - <br /> C2 ROTARY Type of Grout <br /> ❑ CATHODIC PROTECTION -. - <br /> ❑ DISPOSAL <br /> ❑ OTHER...R Other Information <br /> Surface Seal Installed By: <br /> ❑ GEOPHYSICAL — <br /> PUMP INSTALLATION: Contractor - _ <br /> H.P. <br /> Type{of Pump <br /> 'JMP REPLACEMENT: ,❑ State Work Done_+} <br /> _JMP REPAIR: ,. 1'..- ❑ State,Work Done <br /> �' ell Diameter Approximate Depth --� <br /> DESTRUCTION OF WELL: <br /> Discribe Material and Procedure �- <br /> ared this applicationrand that the work will be done in accordance with San Joaquin County. <br /> I hereby certify that I have prep <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> become subject to workman's compensation laws of California <br /> is issued, 1 shatl not employ any person in such manner as to -" <br /> Contractor's hiring or sub-contracting signature certifies the following:"1 certify that i f the performance of the work for which this <br /> permit is issued, I shall employ persons subject w kman's compensation laws of California." <br /> wiH call spieclion prior o groutin and final inspection. <br /> Signed X Titre: <br /> President Date: Mauch 4, 1981 <br /> (Dra of Plan on Reverse Side) <br /> -FOR DEPARTMENT USE ,NNL,Y <br /> PHAS£I (� P O Date <br /> Application Accepted By • Ate-—�—�� <br /> Additional Comments: <br /> Phase11Grout Inspection e� �a t at inspection <br /> Inspection By <br /> Date Inspection By Date <br /> I Fee Is Due:❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&FW. By January 31 ❑ July 1&ReceivedREMITuly 31 <br /> x BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> BASE - EXPLANATION DATE DATE REMITTED AMOUNT <br /> . FEE <br /> r <br /> LESS J <br /> .PRORATION <br /> PENALTY <br /> OTHER -� <br /> OTHER <br /> ` - rmit No. IssuanceDale Mailed Delivered <br /> Q-1-11 h. ate Receioi-No <br />