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Applications Will Be Processed When Submitted Properly Completed. Be li{ fd jq�Thf A4polic t <br /> FOR OFFICE USE:- APPLICATION 1�;F2 �s l� U <br /> (For Non-Transferable, Revocable, Susp le) 1� <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PE L�j.� <br /> (COMPLETE IN TRIPLICATE) WATER QUALITYrfty �in <br /> Application is hereby made totheSan JoaquinLocalHealthDistrictforapermittocanstructand/ori � t��` eelndescribed.Thisapplication+s <br /> {� made in compliance with Wggli. Coau�nj OOr¢inance No. 1862 and the rules and regulations of tl}d an 3t�aquin Local Health District. <br /> CL da. City/Town Lathrop G,. <br /> Exact Site Address <br /> Pete Arellano Phone <br /> Owner's Name <br /> Address14Z?5 S. Avon Latrop. Ca <br /> City Lathrdp f <br /> Contractor's Name Bill Weibel License# 0 Business Phone I' $23-- 16 R <br /> Contractor's Address 1165 N, Main St. P.O.BQX 716 Emergency Phone <br /> h <br /> Is-Certificate of Workman's Compensation Insurance on File With SJLHD? Yes L____ No !: <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTIOND; �Z <br /> WELL CHLORINATION ElWELL ABANDONMENT 13OTHER ❑ PUMP INSTALLATION 13PUMP REPAIR <br /> REPLACEMENT <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy h <br /> Sewage Disposal Field Cesspool/Seepage Pit I! Other y <br /> Property Line Private Domestic Well _ Public Domestic Well <br /> INTENDED USE' TYPE OF WELL I <br /> ❑ II DUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> B DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing _ <br /> ❑ DDOMESTIC/PUBLIC 11 DRIVEN Gauge of Casing <br /> *IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout V" <br /> ❑ DISPOSAL ❑ OTHER Other Information QE <br /> ❑ GEOPHYSICALA. & i3 R0CtxlCace Seal Installed By: 13 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump P. / p LA <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. II <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of thework for which this permit r <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 /> j I will call for a�Glrout Insp ction prior to grouting and a final inspection. <br /> Signed X _ rx .�`y Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> A, <br /> Additional <br /> Application Accepted By Date <br /> Additional Comments: <br /> hase f rout Inspection Phase III Final lnspection <br /> Inspection By Date Inspection By Date t <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑. January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REM iT <br /> BILLING REMITTANCE AMOUNT DUE CHECKED <br /> BASE EXPLANATION <br /> r DATE DATE REMITTED AMOUNT <br /> FEE 45 <br /> LESS <br /> PRORATION <br /> ? PLUS <br /> PENALTY <br /> f OTHER <br /> I <br /> F OTHER - <br /> 7-9 <br /> 1. Received by D to Receipt No Permit No. Issuance Date it Mailed Delivered <br /> U <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 45201 . . <br /> t <br />