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FOR OFFICE USE: <br /> f1 Non-Transferable, Revocable,Suspendable) / PUMP&WELL <br /> / <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 nd the rules an regulations of the San Joaquin Loll Health District. <br /> Exact Site Address of 7 / 17 City/Town <br /> Owner's Name C 1 _. Phone <br /> AddressCity [ <br /> Contractor's Name License# Business Phone ! Y "f I7 <br /> Contractor's Address Emergency Phone oV <br /> Is Certificate of Workmanompensation Insurance oile With SJLH <br /> 's CD? Yes —_ NO <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 7✓ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR 18 <br /> Qf <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <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 mal Installed By: <br /> PUMP INSTALLATION: Contractor ✓7e' <br /> Type of Pump H.P. y <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. F ` <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 /> 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 /> y II call for a Grout Inspectio prior to routing and a final inspection. <br /> ` Y <br /> Signed AL <br /> Title: l"J Date: <br /> (Draw PI Plan on Reverse Side) <br /> �R DEPARTMENT USE ONLY (1 <br /> PHASE I <br /> Application Accepted BywvvDate <br /> Additional Comments: — <br /> Phase 11 Grout Inspection Phas,III nal Inspection <br /> Inspection By Date _.__—.. — — Inspection�/eceived <br /> _ Date Z <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 By January 31 ❑ July 1 &Received By July 31 <br /> — —— REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE VS� rJA - <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY —. <br /> OTHER <br /> OTHER <br /> / _:? <br /> Received by Date Receipt No. Permit No. 4, Aanc Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bos 2009 STOCKTON,CA 95201 <br />