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AWkJ tioMMlll !e Prdq�ed When Submitted Properly Completed. Be Sure To Sig7The pplication. <br /> OFFICE USE: APPLICATION <br /> �A� �II�/���I �1 LttF�o� Mon-Transferable, Revocable,Suspendable) &WELT. / y� <br /> HEALTH DISTRtMIRONMENTAL HEALTH PERMITA <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY y <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 647 t1n City/Town ' 'Stncktrm <br /> Owner's NamePhone 408-245-6749 <br /> C <br /> Address 617 r nrl"C_n1y-- #6 City Sunnyvale <br /> Contractor's Name ,MooYtnan; GWat--P-r .SyStP-CCI License#267696 Business Phone _ <br /> Contractor's Address Emergency Phone - <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_ X No (� <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑l RECONDITION 13 DESTRUCTION❑ C) <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONE) PUMP REPAIR❑ �J <br /> REPLACEMENT❑ i <br /> t <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'WELV-- <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 <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION:. Contractor MOOrmanS' s Water Sys - mg <br /> Type of Pump submersible H.P,_l <br /> PUMP REPLACEMENT: R state Work Done <br /> PUMP REPAIR:i ❑ State Work Done ' <br /> DESTRUCTION OF:WELL: 1 Well Diameter Approximate Depth <br /> Describe Material and Procedure y ` <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 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:'Y certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." , <br /> I will call for a Grout Inspection prior to grouting and a final inspection. , x <br /> Signed X Title: l Date: <br /> i (Draw Plot Plan on Reverse Side) <br /> F. <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection ase Ili Final Inspection <br /> inspection By I Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY' ❑ PER UNIT ❑ PER SITE ❑ EACH'- -❑ January 1 &Received By January 31 ❑ )uiy 1 &Received Sy'July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT pUE CHECKED <br /> , DATE `"° DATE REMITTED AMOUNT <br /> FEE SV S <br /> LESS + <br /> PRORATION - <br /> I PLUS <br /> PENALTY <br /> OTHER <br /> OTHER 3 <br /> Received by Date Receipt No.: Permit No. - --Assulance0kate Mailed Delivered- - - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITJSERVICES 1601 E.HAZELTON AVE_,P.O.Box 2009 STOCKTON,CA 952131 <br />