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FOR OFFICE USE: APPLICATIONF; <br /> j #or Non-Transferable, Revocable,Suspendable) <br /> t I 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 2700 N Arata Rd City/Town Stockton <br /> Owner's Name. Rick Arata Phone Work 931-1470 <br /> Address City Stockton <br /> Contractor's Name License# 371560 _ Business Phone 462-5597 <br /> Contractor's Address Emergency Phone N <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD2 Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ O� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST:- Septic Tank d4�_. Sewer Lines Pit Privy 11 <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 10 5L811 <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing 6 8n <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of CasingSteel <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ___50' <br /> © CATHODIC PROTECTION C ROTARY Type of Grout Bentonite <br /> ❑ DISPOSAL ❑ 'OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> ' <br /> i <br /> PUMP REPLACEMENT: <br /> El 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. <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." <br /> I w' allf or a Grout Inspection prior to grouting and a final inspection. <br /> Signed X Title: Date: 7 , �, <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted B <br /> Date ! I <br /> _ ... _. - I <br /> Additional Comments: - I <br /> _ " a II Gr t Inspectiong~�z�-- Phase III Final Inspection <br /> Inspect,10 By TI C 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 i <br /> REMIT j <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED JI <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS I <br /> PRORATION <br /> PLUS v <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No suanc ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO:' ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E_HATELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 1 <br />