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A tljq tlLO�egrogss6 Mansferable, <br /> ubmittedProperlycomplerea. tse aure Ioalgn 1V�MAAIP <br /> t,Nrr. <br /> FOR OFFIE U <br /> CSE: APPLICATION <br /> SEP <br /> ��,{ or Revocable,Suspendable) <br /> S <br /> - &WELL i <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE)AN JOAQUIN LOCAL WATER QUALITY <br /> Application is hereby made to04F5 UFbAu6[3(Tali&Th District for a permit to construct and/or installthe work herein described.This applicationis <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 8476 City/Town Stockton, <br /> Owner's Name Phone 369-5677 <br /> Address same City <br /> Contractor's Name Mn rManisLicense# 267696 Business Phone 931-3210 <br /> Contractor's Address 4243 cberryl andAve. Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No — --� <br /> TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ } <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR _3 <br /> REPLACEMENT E <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 <br /> JOEOPHYSICAL <br /> ENDED USE TYPE OF WELL <br /> STRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> GATION ❑ GRAVEL PACK Depth of Grout Seal <br /> HOOIC PROTECTION ❑ ROTARY Type of Grout <br /> OSAL ❑ OTHER Other Information <br /> Surface Seal Installed By: <br /> NSTALLATION: Contractor Moormanr <br /> Type of Pump submecy hl o H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure_ m <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 /> Contractors 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 will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X <br /> Title: — Date: Q <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I I"`1� q—t 0—8� <br /> Application Accepted By �J Date <br /> Additional Comments:—A <br /> Phase II Grout Inspection h s III Final Inspectioi <br /> Inspection By Date Inspection By j9d6& Date 3 <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 /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> O <br /> Received by Date Receipt No I Permit No. Iss ance D toMailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />