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Applications Will Be Proceased When Submitted Proper ly,Completed. Be Sure To Sign The Application. 1 FOR OFFICE USE: APPLICATION 14 I Non-Transferable,Revocable, Suspendable) PUMP&WELL Y ENVIRONMENTAL HEALTH.PERMIT (COMPLETE IN TRIPLICATE) r WATER QUALITY ' Application is hereby made to the San Joaquin Local Healtlj District fpr a permit to Construct and/or install the Work herein described.This application is rt}�de in compliance with Un Joaquin County OrdinanceNo. 1862#9.d the rules and regulations of the Sen Joaquin Local Health District. EAact Site Address �.1+,�.r�:-� qEr j.ag City/Sown Tracy _ aLner's Name •_ Phone ese Address n O .—Box--326, m._acy City Modesto at Contractor's Name _4k-PA zzj es 1)p '-g— License X.081} Business Phone545-1 185 t Contractor's Address K��5 RelB.i g,.� +•e - Emergency phone 1+5 1185 Is Certificate of Workman's Compensation Insurance on File With SJLH67 Yes % No Olj TYPE OF WORK (CHECK): NEW WELL bEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ ,r WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR El REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank 100 Sewer Lines Pit Privy ---D Sewage Disposal Field Cesspool/Seepage Pt; Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL Q INDUSTRIAL ❑ CABLE TOOL Dia. of Welt Excavation 1 pit DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 6" P DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing PVC '1 6n ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal %) 8 0 CATHODIC PROTECTION ROTARY Type of Grout IIlEllt ❑ DISPOSAL d OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: T)ri I ler 1 Y PUMP INSTALLATION: Contractor � Type of Pump H.P. _S PUMP REPLACEMENT: ❑ State Work Done - — PUMP REPAIR: ❑ State Work Done - -C DESTRUCTION OF WELL: Well DiameterApproximate 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. 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 shall not employ any person in such rpanner as to become subject to workman's compensation laws of California" Contractor's hiring or sub-cpntracting signature certifies the following:"I certify that in the performance of the work forwhich this C permit is Issued, I shall employ persons subject to workman's compensation laws of California." I will call for a Grout Inspection prior to grouting and a final Inspection, ' v' Date:Title: Signed X � . c (Draw Plot Plan on Reverse Side) r , . .FOR D -ART NT USE ONLY PHASE I Application Accepted By. Additional Comments: Pha II rout Inspectio�n /•7 i / Phase III Final Inspection Inspection By�� Date.slra'��f V Inspection By Date P e Fee 19 Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE - ❑'EACH ❑ January 1 &Received By January 31 ❑ July 1 a Received By July 31 REMIT BILLING REMITTANCE f BASE : EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT ., �r .. - FEE Ll ' W 3• ' LESS �I PRORATION PLUS PENALTY e OTHER OTHER l3 Received Dy O to Recelpt No. Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON•CA 95201