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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora 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 9999 S Austin Rd T. 1S , —R. 2E City/Town Manteca <br /> Owner's Name FORWARD INC Phone 466-5192 <br /> Address P. o. B_OX 6336 City Stockton <br /> Contractor's Name CLARK WF.I,L & FQUIP. CO. JIUcense# 76602 Business Phone 462-5597 <br /> Contractor's Address 2024 F.. Charter Way STKN Emergency Phone N NE <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENTJD OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ v, <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank N/A Sewer Lines Pit Privy , (\ <br /> Sewage Disposal Field Cesspool/Seepage Pit Other V J <br /> Property Line 2 50 t Private Domestic Well= 00 1 Public Domestic Well <br /> INTENDED USE TYPE OF WELL 1y <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing PVC PTPF. (1 <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 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 5", Approximate Depth 901 <br /> Describe Material and Procedure attempt to pull platic casing,fill <br /> tip with cement grout <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 forwhich this <br /> permit is issued, I shall ploy ersons subject to workman's compensation laws of California." <br /> I wil c I for Gro n p fort outing and a final insp/ecc ion. <br /> Signed X Title. vI Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR EPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By °C"^ 'tic-� Dat X47 <br /> Additional Comments: <br /> Phase II GroutA�pe asIII ina I spectionInspection By � `'. InspectioDate `L 1 <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT 0 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 <br /> AMOUNT <br /> FEE It <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> '7a1-1�:7-2 of 2 ?9 <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.Boz 2009 STOCKTON,CA 95201 <br />