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s <br /> Applications Will Be Processed When Submitted Properly Completed.Be Sure ToSignTheApplicailion. <br /> APPLICATION i <br /> FOR OFFICE USE: i <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> i <br /> L ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) <br /> WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work 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 17631 S •HQ-Y'1I-incl-S tt City/Town Lathrop <br /> Owner's Name <br /> 1 emiPhone 8 2 2 r <br /> Address _ 6'7'7'7 City O <br /> Tr . O-W--1aI1Cl 4� <br /> 97 <br /> Contractor's Name C I Rrk e &�( License#�7:1. Business Phone <br /> Contractor's Address _ 024_F.__Chart _r_lTav Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No — <br /> TYPE OF WORK (CHECK): NEW WELLO DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ r <br /> REPLACEMENT❑ <br /> in Ag Fie�d 1 <br /> DISTANCE TO NEAREST: Septic Tank ewer Lines Pit Privy r* l <br /> Sewage Disposal Field Cesspool/Seepage Pit Other ' <br /> Property Line Private Domestic Well Public Domestic Well �1!I <br /> INTENDED USE TYPE OF WELL 1 <br /> 1211 <br /> INDUSTRIAL monitor ❑ CABLE TOOL Dia. of Well Excavation 5 <br /> DOMESTIC/PRIVATE standardSO DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 12 steel <br /> r <br /> ❑ IRRIGATION 1:1 GRAVEL PACK Depth of Grout Seal _ .1911 191 S . <br /> ❑ CATHODIC PROTECTION M ROTARY Type of Grout 9-sack mix �+ <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ 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 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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> i is issued, 1 shall person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's Kiri or sub-contractin u certifies the following:'•i certify that in the performance of the work forwhich this x <br /> permit is issued, 1 ployp son sub' ct to man's compensation laws of California." <br /> I r a r t a t', pri to III g y d a final inspection. <br /> Signed Title: VP-Clark Well & Equip : Date: May 121980 <br /> (Draw Plo Ian on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Date <br /> Application Accepted By <br /> Additional Comments: <br /> haspJI Grout Inspection P111410 III Final Inspection . <br /> Inspection By e Inspection By - V� Date 3 <br /> 4 <br /> Fee Is Due: 11ANNUALLY ❑ PER UNIT ElPER SITE ❑ EACH ElJanuary 1 &Received By nuary 31 [3July 1 &JReceived Fh ut 1 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE 5 AMOUNT DUE CHECKED <br /> 2 DATE DATE REMITTED (� AMOUNT <br /> FEE (43 l <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> I <br /> Received by Date Receipt,No. Permit No. I suancd Date Mailed Delivered <br /> IAPPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 ,STOCKTON,CA,95201 <br />