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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. J ) FOR OFFICE USE: APPLICATION 1.] y Non-Translerable,Revocable, Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH,PERMIT (COMPLETE IN TRIPLICATE) NIATiR.QUALITY Application is hereby made to the San Joaquin Local Health District for a permitto construct and/or install the work herein described.This application is 4-- made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. L Exact Site Address LOT )+ 44.17 W. STONERID DR. -r City/Town TRACY Owner's Name Don Co$P_ • Phone Ai r,—nl.22.p Address 19 E t 6th St o City Contractor's Name HenningS BPO5 Drilling C@icense N 290SJ Business Ph(en!' � Contractors Address 2 Pelandaie Ave.. Emergency Phone 5201-1575 Is Certificate of Workman's Compensation Insurance on.File With SJLHD7 Yes X No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank 1100-- Sewer Lines Pit Privy �l'sy4 Sewage Disposal Fiipld 100' Cesspool/Seepage Pit /Ir.1--e"T . Property Line��Private Domestic Well AJC _Public Domestic Well INTENDED USE r TYPE OF WELL❑ INDUSTRIAL �.CABLE TOOL Dia. of Well ExcavationISI DOMESTIC/PRIVATE 13 DRILLED Dia. of Well Casing It Pynd DOMESTIC/PUBLIC p DRIVEN Gauge of Casing❑ IRRIGATION � GRAVEL PACK Dep(h of Grout Seal ❑ CATHODIC PROTECTION IX ROTARY Type of Grout CE,MEN ❑ DISPOSAL ❑ DTHER Other Information — ❑ GEOPHYSICAL - Surface Seal Installed By: DRTT TFR PUMP INSTALLATION: Contractor _ Type of Pump H.P. PUMP REPLACEMENT: State Work Done PUMP REPAIR: © State Work Done DESTRUCTION OF WELL: Well Diameter _ Approximate Depth Describe Matdrial 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 rulers and regulations of the San Joaquin Local Health District. Homeowner 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 manner as to become subject to workman's compensation laws of California:' Contractor's hiring or subcontracting signature certifies the following:"I certify that in the performance of the work forwhich this permit is Issued. I shall employ persons subi'ect to workman's compensation laws of California." I will call for a Grout Ins e'ctioon prior to grouting and a final inspection, Signed X Title: &tA • Date: (Draw Plot Plan on Reverse Side) F DEPA/RTMENT USE ONLY PHASE I Application Accepted By Additional Comments:• Phase II Grout Inspection Phase III Final Inspection. Inspection By Oate - Inspection By,, sla.pate i I '� 11�'�R,C.t IKfI VSrvtt_ ,�] Fee Is Due: (� ANNUALLY PER UNIT.: ❑ PER SITE EACH ❑ Je uUN 1 &Received By January 1 ❑ July 1 &Recewed By July 31 REMIT BILLING REMITTANCE S BASE EXPLANATION DATE DATE ' REMITTED AMOUNT DUE CHECKED AMOUNT FEE 0111 LESS' PRORATION _ PLUS PENALTY OTHER OTHER �p q 8 ? 0 — Received ey De1e Receipt No. Perms o. I uaee Date Mailed Oel vered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bor 2009 STOCKTON,CA 05201