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VOW UV rlv",.4ru �i auuu uueu rlujieriy �.uniNiuir:u. ,e Buie iU alyli Me HiJpucu.w­ <br /> FOR OFFICE USE: L'' AUG 1 619C <br /> APPLICATION ' <br /> _ tror Non-Transferable, Revocable,Suspendable) PUMP&W", <br /> 13 <br /> SAT'l N, Lpgp(ylRONMENTAL HEALTH PERMIT r <br /> :OfJIPL@TE IN TRIPLICAT�EALTH DISTRICT WATER QUALITY. <br /> Application is hereby madetothe San Joaquin Local Health District fora permit to construct and/or install the work he described.This application is <br /> ade in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> xact Site Address 4350 N. Newton Rd. City/Town _.,._",Stockton <br /> r <br /> Owner's Name WIckila JAimher Co Phone — <br /> 5977i <br /> radress City <br /> ontractor's Name Mnctrm&n r Water ,Sys ems— License#?6769 Business Phone 931-3210 <br /> =�.ontractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes x No <br /> YPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION DESTRUCTION❑ <br /> L2ELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR <br /> REPLACEMENTS <br /> STANCE 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 /> 123 DISPOSAL ❑ OTHER Other tl formation <br /> GEOPHYSICAL Surface Seal Installed By: <br /> UMP INSTALLATION: Contractor Moormanrs W �yst�tns -- <br /> r Type of Pump gqlfhynp-r s ib I a H.P. 1 <br /> PUMP REPLACEMENT: :{ State Work Donut d exti cair1 "17= and reel ar- d Wi th new n>ke <br /> LUMP REPAIR: ❑ State Work Done <br /> !ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> 1 (� Describe Material and Procedure <br /> III, r. 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 /> rHomeowner 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:"1 certify that in the performance of the work for which this <br /> L} 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. <br /> - ems. .r <br /> igned X —� Title: . Date: V/ <br /> i (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 <br /> Application Accepted B Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection �4asI II FI el inspection <br /> Inspection By Date Inspection By Lc2�Jluly <br /> ale ZO <br /> Fee Is Due: ❑ ANNUALLY El PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> r AMOUNT <br /> FEE <br /> 66 �i LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> i <br /> ,Received b]' f {]ale Receipt No. Permit NoAseance d to Mailed .Delivered <br /> APPLICANT—RETURN ALL COPIES TO! ENVIRONMENTAI HFA{T"PFItLITMr RVICFS ieM r uk7ri Tnu AUC an a...sono evni-vTnu eA ec�m <br />