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{ r a Applications Will Se Processed When Submitted Properly Co"kkd. Be Sure To Sign The tion. <br /> FOROFFICE USE: APPLICATION MAY 9 1980 <br /> (For Non-Transferable, Revocable,Suspendable) <br /> UIN LOCAL PUMP&WE;LL � <br /> ENVIRONMENTAL HEALTH AQ <br /> I H DISTRICT <br /> (COMPLETE IN TRIPLICATE)-2 S. e-*SS pi �.. WATER QUALITY <br /> 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 <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District, <br /> Exact Site Address Well #2 0 sAg S ket Yt City/Town Tracer <br /> Owner's Name John Bra s Jr. / / Phone <br /> Address 1.029 Varsity Ct. � — city Mountain View Ca <br /> Contractor's Name Western Well Drilling CO.License# 25182 Business Phone 295.M4U r� <br /> Contractor's Address 1.0. Box 1-09S.J. 951U Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_X No <br /> TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> i WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRF1 <br /> REPLACEMENT❑ <br /> t DISTANCE TO NEAREST: Septic Tank - Sewer Lines Pit Privy <br /> _ Sewage Disposal Field Cesspool/Seepage Pit Other t <br /> f i <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casingt <br /> ❑ IRRIGATION lad GRAVEL PACK Depth of Grout Seal ) <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout N <br /> ❑ DISPOSAL ❑ OTHER Other Information a <br /> ❑ GEOPHYSICAL Surface Seal Installed By: h <br /> 1 t <br />` PUMP INSTALLATION: Contractor k <br /> i Type of Pump—.-Zr'-- ' H.P. i <br /> L <br /> PUMP_REPLACEMENT: „ , r ❑�State..Work_Do.rte <br /> PUMP REPAIR: ❑ State Work Done W f <br /> F DESTRUCTION OF WELL: Well Diameter Approximate Depth li <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> r <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ person subject to workman's compensation laws of California." <br /> I ill I rout Inspection prio to routing and a final ipeclio <br /> Signed Title: <br /> }..l: -)40 in Date: <br /> (Draw Plot Plan on Reverse Side) <br /> I F DEP RTMENT SE ONLY <br /> PHASEI r <br /> Application Accepted By ��� �`"`"�"�" Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phas I mal Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PEA UNIT ❑ PER SITE ❑ EACH - ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> _ BILLING REMITTANCE $ <br /> REMIT <br /> BASE EXPLANATION PATE DATE REMITTED —AMOUNT DUE CHECKED <br /> AMOUNT <br /> I <br /> FEE _ <br /> LESS. <br /> PRORATION <br /> PLUS <br /> �. PENALTY <br /> { <br /> OTHER <br /> OTHER <br /> I <br /> (l72-7 <br /> Received by Date Receipt No. _ Permit No. - - Issuance Date Mailed Delivered - <br /> "" .APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL-HEALTH PERMIT/SERVICES-- 1601 E.HAZELTON AVE.;P.O.Box 2009 STOCKTON,CA 9520 <br />