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Applications Will Be Processed When Submitted Properly Completed. BeSureToSign TheApplication. <br /> FOR OFFICE-USE: — APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL t <br /> ENVIRONMENTAL HEALTH PERMIT j <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY -Z-1— '/ <br /> i <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 Joaqin County_Or_dinunce NQ. 1862 an.d the rules and regulations of the San Joaquin Local Health District. <br /> Well f3 on Vande-=rbrlt .:Circ e Manteca <br /> Exact Site Address ,.=-,w. City/Town <br /> Owner's Name CITY OF MANTECA Phone 239-9511 <br /> Address Manteca City Hall city Manteca Public Works <br /> Contractor's Name Henning Brothers License# 290813 Business Phone <br /> Contractor's Address 3525 Pelandale Ave.Modes to Emergency Phone (209)' 545-1185 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No 0 <br /> TYPE OF WORK (CHECK): NEW WELL 0 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank NA Sewer Lines 100 Pit Privy NA <br /> Sewage Disposal Field NA Cesspool/Seepage Pit NA Other <br /> Property Line 25 Private Domestic Well 500 ' Public Domestic Well NA <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 3 0 <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 16 <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 10 <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 100 <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout cement. <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump Variable speed deep well 1 H.P. 100 <br /> PUMP REPLACEMENT: ❑ State Work Done turbine <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 /> 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, 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 /> it call for a Grout Ins o prior to grouting and a final inspection. <br /> Signed X Title: ±�i,.t9jt.G liC7es 9. Date: <br /> (Draw Piot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _ <br /> Application Accepted By Date <br /> Additional Comments: <br /> 1 .Ph-ase II Grout Inspection a e III Final Inspection <br /> Inspection By Datet -- Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY '❑ PER UNIT ❑ PER SITE ❑ EACH ❑rJanuary 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION DAMOUNT DUE CHECKED <br /> ATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br />'I <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by to J� Receipt No: Perm� <br /> "—� it N � Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.;P.O.Box 2409 STOCKTON,CA 95201 <br /> r _a - _ . - <br />