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ty <br /> Applications Will Be Processed When SulAPtePL`CArT'ONPICIVU. o„ <br /> FOR OFFICE USE, ( <br /> (For Nan-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> -ice- WATER QUALITY 2 �7 � <br /> (CQMPLETE IN TRIPLICATE)_"O C' <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein describfl <br /> ed.This applicatioh�ss <br /> made in compliance with an Joaqu' County OrdYna a No. 1862 4nd the rul and reg it tion of th nSan Joa uin L al Health Distric <br /> j Eract Site Address <br /> Phone <br /> Owner's Name City <br /> 1 Address <br /> Licen a# I Business Phone / <br /> i Contractor's Name <br /> Contractor's Address • rgency Phone <br /> No <br /> Is Certificate of Workman's Compensation 1 s ranee on File With SJLHD? Yes " <br /> TYPE OF WORK (TION C1 WE W ABANDODEEPEN NMENT ❑❑ OTHERO❑RECONDITION❑P INSTALLATION ❑ON DESTRUCTI ❑ PUMP REPAIR❑ <br /> WELL CHLORINATION � <br /> REPLACEMENT❑ y <br /> �() Sewer Cess <br /> DISTANCE TO NEAREST: Septic Tank Lines Pit Privy <br /> oo1!Seepage Pit Other <br /> Sewage Disposal Field 4019 — p <br /> Property Line Private Domestic Well Public Domestic Well <br /> ' <br /> INTENDED USE TYPE OF WELL ,r <br /> , <br /> j ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> C3 DRILLED Dia, of Well Casing <br /> DOMESTIC/PRIVATE Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC 13 DRIVEN <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> � ❑ DISPOSAL <br /> ❑ OTHER Other Information <br /> i ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> ' Weft Diameter Approximate Depth .. <br /> DESTRUCTION OF WELL: <br /> Describe Material and Procedure <br /> I <br /> I hereby certify that l have <br /> prepared <br /> aand reiguaationstion and that the work of the San Joaquin Local Ilbe Healtdone in h District accordance with San Joaquin County <br /> ordinances, state laws, and rules <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 /> is issued, i shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> tify that in the performance of the work for which this <br /> Contractor's hiring or sub-contracting signature certifies the following:"I cer <br /> k permit is issued, l shall employ persons subject to workman's compensation laws of California." <br /> I wil call for akGrout I ection p or to groutin nd final sp ction. <br /> Date: <br /> Signed X ( / <br /> raw Plot Plan on Reverse Sid <br /> I <br /> F RDE ARTMENT SE ONLY / <br /> PHASE I Dater O�� <br /> Application Accepted By <br /> i, <br /> Additional Comments: <br /> hese III Final inspection ; <br /> P se 11 Grout Inspection Date l� Z' -7 <br /> J 10'6­Inspection By ate Inspection By _ <br /> 1 W� C ; <br /> r,-LyBy h a d <br /> Fee 1s Due, ❑ ANNUALLY ❑ PER UNIT ICJj PER SITE ❑ EACH - ❑ January 1 &Received 8y January 31 ❑ J I ReceiveR�EMIIT,f T <br /> r - BILLING REMITTANCE $ AMOUNT CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> µv <br /> r PLUS r� <br /> PENALTY <br /> t <br /> OTHER <br /> OTHER <br /> j o 7 7 19-w,.- l 0 1:717 <br /> Permit No, Issuance Date Mai4ed Delivered <br /> Received by Date Receipt NO <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL-HEALTH PERMIT/SERVICES <br /> 1641 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />