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.r'...��..r..v ......v . .vvv wr.. ....v..vrr........r. , -_... 1 V JlaJll 1/IC AFI`lllb011Vll. FOR'bF-ICE USE: APPLICATION ..;'. - (For Non-Translerable,Revocable,5uspendable) �-` PUMP&WELL Y -- ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) I 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 rr 3de in compliance with Ign Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District- Exact Site Address _T .,�- a Q r+ .. ., — City/Town Tracy Oiwner's Name -Doti-l+ese Phone Address Paty City Modesto a Contractors Name -HA nn1 1'a o^--�-7+v,��n ��--„ l.1� p License# ��3_ Business Phon4�"' 8 P3� - 3 Contractor's Address _1 dale-ye 55 Emergency Phone _ .4.5_1 1 8 5 Is Certificate of Workman's Compensation Insurance on File With SJLHDI Yes X No -- _ t� TYPE OF WORK (CHECK): NEW WELLM DEEPEN ❑ RECONDITION El DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ ^� REPLACEMENT❑ _ DISTANCE TO NEAREST: Septic Tank _ -09 - _ - Sewer Lines Pit Privy ^� Sewage Disposal Field _ .�0_ Cesspool/Seepage Pit Other Property Line Private Domestic Well — Public Domestic Weil INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Die. of Well Excavation 1 211 - R9 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 611 ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing PVC 160 - ❑ IRRIGATION E3 GRAVEL PACK Depth of Grout Seal 50 8 ❑ CATHODIC PROTECTION 4:1 ROTARY Type Of Grout ceinerit - _ ❑ DISPOSAL ❑ OTHER _ _ Other Information r ❑ GEOPHYSICAL Surface Seal Installed By: nT1111QT V PUMP INSTALLATION: Contractor _ Type of Pump -- H.P._ ----�•-- - _-�-�� PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done C DESTRUCTION OF WELL: Well Diameter -____ Approximate Depth C 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. Home owner or licensed agent's signature certifies the following:"I certify that in the performanceof thework 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." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued. I shall employ persons subject to workman's compensation laws of California." C I will call for a Grout Inspection prior to grouting and a final Inspection. Signed X _ Title: _ Dale: (Draw Plot Plan on Reverse Side) FOR DEPART NT USE ONLY PHASE I Application Accepted By - Date✓�~// Additional Comments: PITS II rout Inspectlon1� ./ Phase III Final Inspection Inspection By Date [ Inspection By �i/1• Date ----- Fee Is Due: ❑ ANNUALLY - ❑ PER UNIT. ❑ PER SITE ❑ EACH ❑ January 1 d Received By January 31 ❑ July I &Received By July 31 REMIT BILLING REMITTANCE 5 BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMIT TED [� AMOUNT FEE c 3 l LESS -_- - - - PRORATION PLUS ... --- -------- — - PENALTY _ t OTHER OTHER --i-- - — - --- - - ReceIF ived by D tr. Receipt No. Penna No Issuarce Date Mailed Delivered - APPLICANT-RETURN ALL COPIES TO-. ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.Box 2009 STOCKTON.CA 952DI