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Applications Will Be Processed When Submitted ProperlyCompietea. tse sure Ioai n IneMPP111_0%1Vr1. __1FOR OFFICE USE: APPLICATIONyo <br /> ~r�+ � <br /> (For Non-Transierable, Revocable, Suspendable <br /> PUMP&W>=LCr,.�v <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permitto construct and/or install the work herein described.This application is <br /> made in compliance with San oaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address <br /> 5045 Peach Ave. Manteca, Ca. City/Town Ilan <br /> teca, Ca. <br /> Owner's Name Deanna Forrest Phone <br /> 5045 Peach Ave. City Manteca <br /> Address 23..441 <br /> Contractor's Name A. & B. Electric License# Business Phone <br /> Contractor's Address <br /> 11 5 North Dain St. Emergency Phone 8'23'4416 <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❑ �Y <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR u <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 D <br /> S. <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 /> t <br /> 11IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal F,S <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> El DISPOSAL <br /> 11 OTHER Other Information <br /> { <br /> ❑ GEOPHYSICAL Surface Seal Installed By: �f1 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ® State Work Done Install claper in boot & al <br /> 1�ve l se <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. <br /> Home Owner or licensed agent's signature certifies the following:"i certify that in the performance of the work forwhich 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 lye <br /> I will call for a Gro spection prior to grouting and a final in�v�erseSid,) <br /> At 8492, 9-18_79 <br /> Signed X Title: Date: <br /> raw Plot Plan on <br /> OR PARTM NT USE ONLY <br /> PHASE 1 _ d Q <br /> Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date 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 /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 16- <br /> LESS LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> -7 /7 7 D 7r5 <br /> Received by Date Receipt No. Permit No, IssuanceDate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9520 <br /> _ s� <br />