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pp i t ol��,hfitilhBig�rJJ;e1,ed h bmitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: € A� PPLl ATION <br /> SEP <br /> 8 �fFiO�Non- ransferable, Revocable, Suspendable) n!C <br /> MP Ox %AIELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> r <br /> (COMPLETE IN TRIPLICATE)SAI-1 0 1 L WATER QUALITY <br /> Application is hereby made to the 46E aptrhLo1 ! i ftklDistrictforapermittoconstruct and/or install thework herein described.This application, <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_ _6196 -Amaride Court _ City/Town Stec kt�nn <br /> Owner's Name Gdr —Cavana h <br /> �- Rhone .��=-26-7-8-- _ <br /> Address safne _ Gty — <br /> Contractor's Name - 3�rtTlan' s 6 tPr_ ._�y License#267696_ Business Phone 931-3-2. 10 <br /> Contractor's Address 4243 rhe 1 and -ANil Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_X _. No _ <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ f�� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ® PUMP REPAIR v <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank _..._ Sewer Lines _ Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit .. Other_. _ <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 Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information .. <br /> ❑ GEOPHYSICAL Surface Seal Installed By: _ <br /> PUMP INSTALLATION: Contractor Moorman' S water systerCl_5__ —_ <br /> Type of Pump <br /> PUMP REPLACEMENT: Ik State Work Done- rent:]Aced _ex-ist�n� pump vi-th--new 2up <br /> PUMP REPAIR: ❑ State Work Done _ <br /> DESTRUCTION OF WELL: Well Diameter _ Approximate Depth <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 Heaith District. <br /> Home owner 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 persons subject to workman's compensation laws of California" <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X Title: _ f �'-?/ <br /> __C?— 2c' Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted Byeri,� 1 — Date <br /> Additional Comments:_. <br /> Phase II Grout Inspection Phase III Final Ins ection <br /> Inspection By Datec <br /> Inspection By .._ Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE REMIT <br /> BASE EXPLANATION $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> JQ 1 C <br /> LESS -- <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> t7 <br /> OTHER - - - - <br /> OTHER <br /> Received by Date Receipt No. Permit No. �anc Date Mailetl Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />