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r Applications Will Be Processed When Submitted Properly Completed. Be 5 rl�o§t�nTheApplication. I i <br /> FOR OFFICE USE: APPLICATION 13 ���d '=� <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> _ SAN .�n,rQU1N LOCAL � <br /> (COMPLETE IN TRIPLICATE) ?, "f�.'%1 _,4-cid ,._WATER QUALITY HEALTH DISTRICT <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 Joaquin County Ordinance111862,, /and th,p rules and regu tions of the San Joaquin Local Health District. <br /> ,Exact Site Address ��tgap ���%1rr" /y���z rru', City/Town <br /> `'Owner's Name Lagero Business Enterprise 20 <br /> Phone <br /> Address City <br /> Contractor's Name StaniS.laUS F]jW License#A290355 Business Phone 522-9027 <br /> Contractor's AddresP- Or CA. Emergency Phone 3-ame <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ I <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION IR PUMP REPAIR 11 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines= Pit Privy <br /> �+r <br /> Sewage Disposal f=ield Cesspool/Seepage Pit Other i <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL j . <br /> ❑ -INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation i <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 13:IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal A� <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor slaus <br /> Type of Pum H.P. 75 <br /> r PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done 1 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth ffi <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." t <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X � Title: rate: —12-32-80 <br /> (Draw Plot Plan on Reverse Side) <br /> d <br /> R D ARTME USE ONLY i <br /> PHASE n <br /> Application Accepted By �� "" Date rS b <br /> Additional Comments: <br /> Phase II Grout Inspection P'ase 111 Final Inspection i <br /> Inspection By Date Inspection By Date n <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION PATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> E, <br /> Received by Date - Receipt No. Frermit No. Issuance Date Mailed - Delivered,- <br /> APPLICANT—RETURN <br /> elivered!APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE:,P.O.Box 2009 STOCKTON,CA 95201 _ <br />