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17 Uy 'cations Will Be ProcessedN <br /> Submitted Properly Completed. Be Sure To Sign The Application.FOR OFFICE USE: r161982 APPLICATION <br /> AUG#9l� (For Non-Transferable, Revocable,Suspendable) PUMPSAN JOAQUIN &WEL <br /> IRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATLIEALT14 DISTRICT ,WATER QUALITY, - <br /> Application is hereby madeto theSan Joaquin Local Health District fora permit to construct and/or install thework herein described.This application is <br /> made in compliancewith San Joaquin County Ordinance No. 1662 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address_ A350 N.- Newton Rd. City/Town <br /> stockton <br /> 1. _' Phone _ <br /> Owner's Name <br /> Address ' i f`- City <br /> -Stockton <br /> Contractor's Name Mnnrrnant g ,wat Vat-Ams License#77696 Business Phone —3 210. f <br /> Contractor's Address 7120 Wi l rnx Rrl L 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'❑' RECONDITION El DESTRUCTION❑ v ' <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT W <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 t <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 13 ROTARY Type of Grout _ <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 1 <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: 411. Contractor Ma rnnanWater <br /> Type of Pump submersible H.P. <br /> PUMP REPLACEMENT: State Work Done :pill I ed ext J <br /> PUMP REPAIR: ❑ State Work Done <br /> L_ DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> �'� —TD'escribe'Nlate-riaf-and-Procedure—•'A-•'---= <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 for which this permit <br /> is issued, t 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 /> i permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 1 <br /> I will call for a Grout Inspection prior to grouting and a final inspection. , <br /> s -� Title: <br /> - Date: �/ y <br /> Signed X <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE Ibt- <br /> Application Accepted By Date <br /> h <br /> _Additional Comments: <br /> Phase II Grout Inspection as II Fi al Inspection <br /> Inspection B �L e _2 7-3? <br /> Inspection By , .Date_ _ �w P y <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 /> t DATE DATE REMITTED C AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY;, <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. - suance D.to -_ Mailed 'Delivered'' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />