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lications- I�Be RibBksedWhen Submitted Properly Completed. Be Sure To Sign The Application. "FOFT'60FICt USE: ,]A AL APPLICATION 1pA `- Ce�Non-Transferable, Revocable,Suspendable) SAN JaH D�SN ENVIRONMENTAL HEALTH PERMIT PUMP&WELL �- .41 (COMPLETE IN TRIPLICATE)N�P t WATER QUALITY Q 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 made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. 9 Exact Site Address 121.$7 Union Rd. City/Town Manteca F ;, Owner's Name Glen Biggs Phone 982-5668 Address 12187 Union Rd City Mantena Contractor's Name Moorman r s Water Systems License# 267696 Business Phone 9 31-3?-t n Contractor's Address 4243 erryland Ave. Emergency Phone same Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR REPLACEMENT❑ I DISTANCE TO NEAREST: Septic Tank —. ,Sewer tines-- -- Pit Privy. - -- "i Sewage Disposal Field Cesspool/Seepage Pit Other �. Property Line Private Domestic Well Public Domestic Well INTENDED USE I TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE- DRILLED Dia, of Well Casing i ❑ DOMESTIC/PUBLICP DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout i ❑ DISPOSAL ❑ OTHER Other Information El GEOPHYSICAL Surface Seal Installed By: N PUMP INSTALLATION: Contractor Type of Pump H-P, ` PUMP REPLACEMENT: El SState Work Done PUMP REPAIR: f} l7 state Work Done DESTRUCTION OF WELL: Well Diameter Appro (mate Depth Describe-Material and Procedure hereby certify that i have prepared this application and that the work will be done in accordance with San Joaquin County j ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. I Homeowner or licensed agent's signature certifies the following:.l certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California"- Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ'persons subject to workman's compensation laws of California," i 1 will II for a Grout Inspection prior to grouting and a final inspection. _ f Signed Title: 10' -�� l� Date:,,Z (Draw Plot Plan on Revers Side) 9 FOR DEPARTMENT USE ONLY PHASEI # Application Accepted By . Date Additional Comments: Phase I Grout Inspection 4 P sP III Final Inspection ) Inspection By— Date ' ''Inspection By Date I Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH 0 January 1 &Received By January 31 ❑ July 1 &Received By July 31 BILLING REMITTANCE $ REMIT i BASE - EXPLANATION, DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT i r FEE LESS PRORATION y PLUS PENALTY c OTHER 9 OTHER Received by Date i Receipt No Permit No. 0 BSG Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICESAq l I , 1604 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 9520 1 1 +�1I1 I _. .