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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 z- ENVIRONMENTAL'HEALTH"PERMIT (COMPLETE IN TRIPLICATE) t,WATER QUALITY. -, � 01 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 648 W. Bianchi City/Town Stockton " Ca. # Thh The Thompson Group Owner's Name � p Phone 1'951-944$ Address 4632 Georgetown Plaza City S' Ston=ckton Contractor's Name World Enterprises, Inc. License# 265964 Business-Phone 466x0717 y Contractor's Address 3927 Clark Dr. "Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No QJ TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ "'RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENTS 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 t TYPE OF WELL ; ❑" INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ... ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN T Gauge of Casing" ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY" xFType of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done _ ' DESTRUCTION OF WELL: Well Diameter t"� -`=`' f 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 rule and regulations of the San Joaquin Local Health District. Homeowner or licensed agent's,signature certifies the following:"I certify that in the performanceof the work for which this permit G 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 forwhich this permit is issued, I shall employ persons subject to workman's compensation laws of California." ' I I will II fo a Grout Inspectio - rior to grouting nd a final inspection. Signed X Title: Office Mgr. Date:.6�11�81 F � (Draw Plot Plan on Reverse Side) ' FOR DEPARTMENT USE ONLY PHASE I � I Application Accepted By { Date Additional Comments: Phase II Grout Inspection Phase III Final Inspection Inspection By 1f1 Date Inspection By Date Fee IS Due: ❑ ANNUALLY ❑"PER UNIT ❑ PER SITE ❑ E'ACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT OUE CHECKED DATE DATE q,REMITTED AMOUNT FEE LESS PRORATION Aff PLUS PENALTY / _ OTHER OTHER Q S Received by- rate Receipt No. Permit No. Issuance Date Mailed Delivered. + APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 ,/