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AppucatlonsWill BeProcessed When Submitted Properly Completed. BeVfoSign—The Application. 1 <br /> FOR Or-F11 SSE: APPLICATION �`,'J <br /> (For Non-Transferable, Revocable,Suspendable) APR 10 1980 <br /> ENVIRONMENTAL HEALTH PERMITre s 1 PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY CJQ f THIS <br /> HEALTHHEALTHp4STRIOTRICT <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 Joaqui Local H alth District. <br /> Exact Site Address . High3gay 120 City/Town Man eca, a. <br /> Owner's Name Tony Gonsalves 823-3835 <br /> Address 56 �. H1Yy. l20 Chane CJ <br /> City Manteca, a. <br /> Contractor's Name 8111 Weibel A. &B Elect$ �cense# 2 60 Business Phone <br /> Contractor's Address P• 0. Box 746 1165 N. Main St'Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes tz No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <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 di <br /> ❑ GEOPHYSICAL Surface Seal Install e By: <br /> PUMP INSTALLATION: Contractor is jc <br /> Type of Pump �' H.P. <br /> PUMP REPLACEMENT: 0 State Work Done <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 Health District. \O' <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 subject to workman's compensation laws of California." <br /> �Iwil a Gro u ection prior to grouting and a final inspec ' n. <br /> Signed X -.��.+ _. Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FO DEPAR ENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date 1, <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 A Received By January 31 13 July 1 &Received By July 31 <br /> BILLING REMITTANCE g REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> M -/, 0 .300 t Q 3� <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.Box 2009 STOCKS k)201 <br />