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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE 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 District fora 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 5105 Lovely Rd .-between Old Hwy 0 &r BiU4/-1dra <br /> Owner's Name Joe CueSta Phone $ LI- <br /> Address 5105 Lovely Rd . city <br /> Contractor's Name Henning S Bros. License#290$1 Business Phone 54 5-118 �n <br /> Contractor's Address 2 Peianda ie Moa o Emergency Phone 545-0271 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes x No O <br /> TYPE OF WORK (CHECK): NEW WELL IX DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ [�RR <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ V1 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 11 3 t Sewer Lines Pit Privy I <br /> Sewage Disposal Field 1131+ -Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL 1 tt <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 8ti RV <br /> IM DOMESTIC/PRIVATE E] DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 160 WALL <br /> M IRRIGATION GRAVEL PACK Depth of Grout Seal 501 <br /> ❑ CATHODIC PROTECTION -XI ROTARY Type of Grout BENTONITEr� <br /> ❑ DISPOSAL ❑ OTHER Other Information [SLAB—BY OWNER <br /> ❑ GEOPHYSICAL Surface Seal Installed By: DRILLER <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P, t <br /> PUMP REPLACEMENT: ❑ State Work Done I� <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 /> Homeowner <br /> istrict_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 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. y <br /> Signed X F Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final Inspection <br /> Inspection ByspJ <br /> Inspection By ate <br /> Fee IS DUe: El ANNUALLY ❑ PER UNIT PER SITE EAC ❑ January 1 &Received 6y January 31 ❑ Ju3y 1 &Received 6y July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED - AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> US <br /> PENALTY <br /> t <br /> OTPLHER <br /> s <br /> OTHER <br /> 191AII-7 <br /> Received by Date Receipt No- Permit No. Issuance Date Mailed elivered l <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AYE., .O.Box 2009 STOCKTON,' A 01� <br />