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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. j FOR OF-BICE USE: APPLICATION ! ~ Y (For Non-Transferable, Revocable,Suspendable) f PUMP&WELL f r y� ENVIRONMENTAL-HEALTH PERMIT /! (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 made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address r;y rrr lot* �L Holt—_ Gity/TownTracyAr Owner's Name nru- -M-oyer and LU11or Phone Address 1409—]ZI.!!r9d_!$ '„ City TMCY, Contractor's Name License 564921 Business Phone 83787 I Contractor's Address Emergency Phone _4!Z8_60!ZA Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes7L No TYPE OF WORK (CHECK): - NEW WELL El DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 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 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 PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information f ❑ GEOPHYSICAL Surface Seal Installed By: ~1 PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: . ❑ State Work Done PUMP REPAIR;,_ State Work Done B> aced dpva e-d-motor- sins a _ �- DESTRUCTION OF WELL: _ Well Diameter--- - Approximate Depth E f I Describe Material and.P'rocedure 1 't i 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. ' Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit ; is issued; I-shallnot 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 i$ issued, I shall employ persons subject to workman's compensation laws of California." I will or a Gro pect'on or to grouting and a final inspection. Signed X Title: i-o nt rac:m r Date: 1--29-1982 (Draw Plot Plan on Reverse Side) t � FOR DEPARTMENT_ USE ONLY ! : w,-_-,sem.m.,-,••-,�-:-,---••---�_-:::- - ---- - - _ ., � �•�-- ,._....... �_ w -.. _._ - _,.:...PHASE 1- 4' /2Z�Z Application Accepted By Dale Additional Comments: �� ? Phase It Grout Inspection S .J Ph a 1 1 Inspection Inspection By Date _ _ _; -Inspection By -Date' Fee Is--Due:'❑ ANNUALLY Q PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July i &Received By July 31 f REMIT ' BASE EXPLANATION" BILLING REMITTANCE. $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT A ar ' FEE i LESS ` } PRORATION - PLUS 1 PENALTY OTHER d OTHER 11 -Received by. .Date - Receipt No. - .Permit No. issuancb Date Mailed ' Delivered. APPLICANT—RETURN ALL COPIES TOS ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201