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Applications Will Be Processed When Submitted Properly Completed. Be SureToSign TheAppncauon. <br /> FOR OFFICE USE: I APPLICATION <br /> I, <br /> (For Non-Transferable, Revocable,Suspendable) 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 permitto construct and/or install the work herein described.This application is fI <br /> made in compliance with San Joaquitnty Ordinance No. 1882 and the rules and regulatioZHUns of the San Joaquin Local Health District. Q <br /> Exact Site Address E. Highway 120 City/Town Lathrop <br /> Tim Vasquez} Phone 858-4332 } <br /> Owner's Name La llrop <br /> 0 6 <br /> Address City <br /> A, & B, ec rIc License# 28 Business Phone 23-441 <br /> Contractor's Name none <br /> Contractor's Address 11 5 Id, Hain St. Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 3C No ` <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ p�] <br /> WELL CHLORINATION ElWELL ABANDONMENT 13OTHER 1:1PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other j <br /> Property Line Private Domestic Well "— Public Domestic WeH <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <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 ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information ' <br /> ❑ GEOPHYSICAL Surface eal Installed By: d <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done i <br /> PUMP REPAIR: <br /> State Work Done install new Su iso dr <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 or licensed agent's signature certifies the following:A 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 /> *will for Gro spection prior to grouting and a final inspe ' n.SignedX Title: Date:�-- (Davv Plot Plan on R(verse Side} <br /> FO DEPARTMENT USE ONLY ; <br /> PHASE I Date 2 <br /> Application Accepted By <br /> Additional Comments: <br /> Phase Il Grout Inspection <br /> Phase ill Final Inspection <br /> Inspection By <br /> Date Inspection By Date <br /> YY. <br /> Fee IS Due: ED ANNUALLY. ❑ PER UNIT PER SITE EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> RASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> g 037,5 Q dao 7 <br /> Received by ate. I Receipt No. Permit No. Issua a Date _ Mailed Delivered ,- <br /> APPLICANT=RETURN ALL COPIES TO: iLENVIRONMENTAt HEALTH PERM1TfSERVICES 1501 E.HAZELTON AVE.,P.O.box 20119 STOCKTON;CA 9520" <br />