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Type of Pump <br /> <br />0 State Work Done <br />El State Work Done <br />Well Diameter <br />Describe Material and Procedure <br /> Date Lk( s I E <br />Jan...ary 1 & Receive 0 PLR S;'E LI FA.C.H <br />!SWUNG REMITTANCE <br />17A I E 0A7E REMiTTFn <br />AMOUNT DUE <br />Received by Date <br /> APPLICANT—RETURN ALL COPIES TO: <br />- - <br />No <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />FOR DEPARTMENT USE ONLY <br />PHASE I <br />Application Accepted By <br />Additional Comments <br />Inspection <br />Fee is Due: 0 ANNUALLY 0 PER UNIT <br />BASF <br />PLUS <br />PENALTY <br />OTHER <br />CEE <br />LESS <br />PRORATION <br />(ii HER <br />nate Inspection By <br />Phase II Grout Inspection <br />EXPt_ANA i ION <br />V Jankvary o July 1 & Received Cy <br />REMIT <br />CHECKED <br />AMOUNT <br />'47 —/eg <br />Issuance Date Del,vered <br />_ <br />1601 E. HAZELTON AVE.. P0. Boa 2000 STOCKTON, CA 96201 <br /> ...•••••• <br />Phase III Pi al spectIon <br />ate <br />AFFLIL,14 I ILAN <br />(For Non-Transferable Revocable. Suspendahle) <br />EliVIRONMENTAL HEALTH PERMIT <br />(COMPLETE IN TRtPLICATE) NCIII 65 WATER QUALITY <br />Application is hereby made to the San Joaquin Local Flealth District for a permit to construct and/or install the work herein described. This application is <br />made in compliance with San J aquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br />Exact Site Address 14_.1.1-2k. /Lk CityiTown <br />Owner's Name <br />FOR OFFICE USE: <br />PUMP & WELL <br />Phone -1 — 7 7 <br />City <br />License #/(...2-3 73 Business Phone 3 <br />Emergency Phone <br />Compensation Insurance on File With SJLHD? Yes No <br />NEW WELL 0 DEEPEN 0 RECONDITION 0 DESTRUCTION CI <br />WELL ABANDONMENT 0 OTHER 0 PUMP INSTALLATION [KV- PUMP REPAIR 0 <br />Address / <br />Contractor's Name <br />Contractor's Address _ / O -.3 I <br />Is Certificate of Workman's <br />TYPE OF WORK (CHECK) <br />WELL CHLORINATION 0 <br />REPLACEMENT 0 <br />DISTANCE TO NEAREST: <br /> Septic Tank Sewer Lines Pit Privy <br />Sewage Disposal Field Cesspool/Seepage Pit <br />Property Line_ Private Domestic Well Public Domest <br />INTENDED USE TYPE OF WELL <br />9 INDUSTRIAL 0 CABLE TOOL Dia. of Well Excavation <br />DOMESTIC/PRIVATE 0 DRILLED Dia. of Well Casing <br />DOMESTIC/PUBLIC 0 DRIVEN Gauge of Casing <br />1K IRRIGATION 0 GRAVEL PACK Depth of Grout Seal <br />CATHODIC PROTECTION 0 ROTARY Type of Grout <br />DISPOSAL. 0 OTHER _ Other Information <br />GEOPHYSICAL <br />PUMP INSTALLATION: Contractor _ p <br />Surface Seal I stalled By: <br />PUMP REPLACEMENT: <br />PUMP REPAIR <br />DESTRUCTION OF WELL: <br />Other <br />c Well <br />H P 174_0 <br />Approximate Depth <br />Signed X <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 />Horne 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 for which this <br />permit is issued, I shall employ persons subject to workman's compensation laws of California." <br />I ra Grout pectlon p ' r to grouting and a final inspection. ep ,-- <br />— irlt.a,,v Plot*Feanoen: Revers ide) <br />Date: Z-7/