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T Applications Will Be Processed When Submitted'Properly Completed. Be Sure To Sign The Application. OFIMCE USE: APPLICATION F (For Non-Transferable, Revocable, Suspendable) PUMP& II ELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE INTRIPLICATE) WATER QUALITY I Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. j Exact Site Address 1141 North Beecher Lane City/Town Stockton 1� Owner's Name John Armanino Phone 931-3627 F� Address, orth Beecher ne Citytockton Contracts NameClark Well & E ui ment License 9371560� Business Phone x.62-5597 .-. Contractor's Address 2024 E Charter Water Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No TYPE OF WORK (CHECK): NEW WELL® . DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ ' WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT,❑ i DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy gg + Sewage Disposal Field Cesspool/Seepage Pit Other I Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL r 1:1 INDUSTRIAL ❑ CABLE TOOL Dia- of Well Excavation 10 5�81� 0 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 5 8n El 12 DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 50'- 11 0r _❑ CATHODIC PROTECTION ® ROTARY _ Type of Grout Bentonite IM E ❑ DISPOSAL ❑ OTHER Other Information /� 1M 13 GEOPHYSICAL !_ Surface Seal installed By' (�VI �I PUMP INSTALLATION: Contractor ii4e�.W 11 - Type of Pump H.P-_, PUMP REPLACEMENT: ❑ State Work Done i� s PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure I hereby certify that 1--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. R � Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this p'lermit 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 sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this 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. j r Signed X Title: kw.�7f PA _J. a Date: " T (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY �! Pf-IASE I { � ' Application Accepted By, rm&L Additional Comment hase,11 out Inspection Phase III Fina(Inspection ��ii i Inspection B mate ZO d Inspection By Date r� ysaa. a Fee Is Due: 11 ANNUALLY - ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Jufy 1 &Received By July 31 BILLING EMITTANCE $ REMIT BASE ,4VEXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE Law/ LESS !I ' PRORATION A b PLUS PENALTY OTHER OTHER �I Received by Date Receipt No. Permit No Is uance Date Mailed Delivered�P. APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.MAZELTON AVE.;P.O.Box 2009 STOCKTON,CA 95201