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Applications Will Be Processed When Submitted Property Completed. Be SureSfa n. FOR OFFICE USE* APPLICATION ( � `' ; -? ' (For Non-Transferable, Revocable, Suspends ple Jai { ENVIRONMENTAL HEALTH PER MhY21 g81""P ELL (COMPLETE IN TRIPLICATE) i WATER QUALITY Application is hereby made to the San Joaquin Local Health District for a permit to construct and/orins8fal*wW�QLdi!ftek0&4 ,This application is made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of t*ggMe C Te fth District. Exact Site Address 5749 Harrisburg City/Town toc C Owner's Name Lincoln Unified School Dist. Phone 447-9391 Address 2010 Swain City Stockton Contractor's Name Noack Pump Co. License# 355213 Business Phone 948-8817 Contractor's Address 4500 E. Fremont St- Emergency Phone Sam[a I { Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ -� WELL CHLORINATION IN WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 13 REPLACEMENT❑ t DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy -_ r Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well ( INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACT( Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information F ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor s Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: State.Work Done Cleaned., repaired, -antJ extended purnp.- 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. Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." C tractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this h f per it is ied, I mploy persons subject to workman's compensation laws of California." I I c II Gr In ction pri to grouting and a final inspection. Signe Title: Salesmmtanager Date: 5-19-81'- (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY t PHASE Q I Application Accepted By �nmDate Additional Comments: - I Phase II Grout Inspection III F0391 Inspection Inspection By - �.(�� Date Inspection By Date I Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 I BILLING REMITTANCE $ REMIT BASE EXPLANATION PATE DATE REMITTED AMOUNT DUE � CHECKED I AMOUNT FEE LESS PRORATION PL US F PENALTY . OTHER OTHER' r . Received by - Date Receipt No. Permit No (ssuanc6 Dald Mailed Delivered P-, =�-i } • APPLlCANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 -STOCK TO,M CA 95201