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Applications Will Be Processed When Submitted Properly Completed. B u ISIS }�4 plication. <br /> .-OFFICE USE: APPLICATI j1LtJ� <br /> i <br /> a, (For Non-Transferable, Revoc , Sa le) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEA PEIT1. 1980 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY 11l- <br /> Application is hereby made totheSan Joaquin Local Health District fora permit to construct a /Qrri[15 � k w Akin described.This application is <br /> made in compliance with San. C ira eoun�tj?r, nQ nigV,AVS�and the rules and re� !ll� � h l lJtYd uin Local Health District. <br /> Exact Site Address L H I /Town Manteca <br /> Y <br /> Owner's Name Mike Buel.er Phone 916-533-3670 <br /> Address OX 21841 City Oro'ville, Ca. 95965 <br /> Contractor's Name License# 286086 Business Phone $23' 4 <br /> 16 <br /> Contractor's Address ' Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 4 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other_ _ <br /> k <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 /> 11 CATHODIC PROTECTION El ROTARY Type Of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Sur ac Se I stalle <br /> PUMP INSTALLATION: Contractor A. & $• Elects D or � c�p <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: CZState Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure t <br /> fllk <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 /> Homeowner 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I wil/-C <br /> fora Inspection prior to grouting and a final inspectio p� <br /> Signed X f� � _ Title: _o- ilsC�z/ Date: 4 *rC1 <br /> (Draw Plot Plan on Reverse Side) <br /> FO DEPARTMENT USE ONLY <br /> PHASE ] <br /> Application Accepted By '" Date <br /> Additional Comments. <br /> Phase 11 Grout Inspection ha a 111 al Inspec tio <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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS = <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No, Permit No. Issuance Dale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICE# 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9520 + <br /> .ZF <br />