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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) v <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetotheSan Joaquin Local Health Districtfora permitto constructand/or install thework 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 14600 S . Austin-Ed City/Town Manteca <br /> Owner's Name Manteca Unfied School District Phone 239-1279 <br /> Address 2901 F T oUls_P,P@,box 32 City M9nteCa _ n <br /> Contractor's Name Clark Well & Equipment License#371560 Business Phone 462-559-7 <br /> 1 <br /> Contractor's Address 2024 F Charter Way Emergency Phone NA <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL Ea DEEPEN ElRECONDITION 11DESTRUCTION❑ -� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 135' Sewer Lines — Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line'.4:�r Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL 11 CABLE TOOL Dia. of Well Excavation <br /> 1411 <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 1 0" <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 1 SS <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 501 <br /> ❑ CATHODIC PROTECTION ® ROTARY Type of Grout P c'1r Illi x <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor -C <br /> Type of Pump H.P. 6 <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth cn <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 /> 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 for which this <br /> permit is issued, I shall employ persons sub' c wor an's ompensation laws of California." <br /> I will call for a Grout Inspection ' r t o n a ns ection. <br /> Signed X Michael R Clark _ V TATITT.T. Date: August 4 .1981 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / D <br /> Application Accepted By Ct Date a / <br /> Additional Comments: <br /> PJwseJI Grout Inspection Phase III Final Inspection <br /> Inspection By Date 'C�l— -�� Inspection By \U�Ac Date %—\Z, -% <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE FQ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> C <br /> Received by Date Receipt No. Permit No. Is ance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952 <br />