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Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTheApplication. <br /> FOKOFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install thework herein described.This application is <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 P City/Town math <br /> Owner's Name O Phone__. 815B 25 <br /> p <br /> Address City Lathrop � <br /> w <br /> Contractor's Name Wa tt?Y Devela�am n _COrp. License#-2 ---3Z(3- Business Phone(916662-2$29 -C <br /> Contractor's Address 22Cl N. Emergency Phone (9 .6 66.2..-2.92 ',f <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No _ <br /> TYPE OF WORK (CHECK): NEW WELL IR DEEPEN ❑ RECONDITION❑ DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <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 /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 5 <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing - <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION 0 ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> Q GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 5 i nGb Approximate Depth 1 50-200_T_ <br /> Describe Material and Procedure cPmAnt arnntgaa Ota 1 -Path <br /> to siirfai;e, placers through drill DiDe or trpTni e pipe- <br /> 1 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 /> Home owner or licensed agent's signature certifies the following:"i certify that in the performance of the work forwhich 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 /> I I call fo rout spe prior to grouting and a fin s lion. �(� C; <br /> Signedil` Title: f� T c `fly- Date: ,`\C1y t <br /> (Draw Plot Plan on Reverse Side) r E , eat th Safety May 27,1980 <br /> v <br /> emica <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I g(� <br /> Application Accepted By Date <br /> Additional Comments: - <br /> Phase II Grout InspectionP III Final Inspection p <br /> Inspection By Date Inspection Bye P 11 - Da YZ� , <br /> 71 <br /> � 7t�-`'.� <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received January 31 �uly if&R¢ceJuly 31 <br /> REMIT <br /> BASE EXPLANAT4ON BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 3 00 / <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> �1(�O03Fro <br /> Received by Date Receipt No. ernut No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boy 2009 STOCKTON,CA 95201 <br />