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FOR OFFICE USE: APPLICATION r"ter
<br /> ' - IFor.Non'•ft-ransferabie,>iievocable, Suspendable)
<br /> 1
<br /> C' " ENVIRONMENTAL HEALTH"PERMIT
<br /> i .(COMPLETE IN TRIPLICATE)
<br /> i' Applicationisherebymade.totheSan'JoaquinLocalHealthDistrictfora.permitto.constructano/orinstafhthe:work,berein.desoribed...Thisapplicationis
<br /> s
<br /> x rrStatie in compliance lri€.tfi'San:Joaquirlc ourtjc.Ordinance.f�lo_'k$fi2,arrd �,,rotes 8ndgwlations of.tFre,San. oaclin:LocaE Health District.:
<br /> Exact.:Siie Address.
<br /> :Owner's Name _Phone,
<br /> + ..-Address: Z City �
<br /> +.:. Contractor's Name. c.;License#•' _ '7� -Business Phone ;' .
<br /> --,.�onIractor-s.Address s E(nergency..Ph.O;)e
<br /> I :tsCertificaie,oPWorkman s Coinpensatlo>s Insurance on;File Wlth SJLHD� :;, Yes
<br /> TYPE'.OF''WORK (CH.ECK) NEW WELLI]. -DEEPEN RECOf�tDITIpN 0. DESTAi7CTiDN�
<br /> ! '.1VSIELI"'CHLORINATtON 0 V17EiM--KABANDONMENT ©".. OTHER-U ..`P13MP INSTALCATIDN, "PLIiVIPfiEPhiFi�
<br /> REPLACEMENT© ,
<br /> Pit!Privy DISTANCE TO NEi4REST ^1Septic Tank : SewerXines
<br /> ..
<br /> ',:S pa
<br /> Field. r,zCesspoo.l/Seepage Pit. _ :Other
<br /> _. '_Pxoperly.Unee :'Private:Domesti ',Well ePuttlic.:Domestic WeU t'..
<br /> NTfNDED.USE s -TYPE_.OF WELL
<br /> .:
<br /> INDUSTRIAL y D%CABLE.TOOL :Dia.,of,W_ell Excayation�
<br /> -E 'DOMEST!IC/PRIVATE,- s_ ,.:DRILLED .:Dia-:.of WeI Casing.
<br /> I DOMESTIC/PUBLIC ©'DRI.VEN -:Gauge.:ofta�§ing
<br /> ,.::D"IRRIGATION ©-:GRAVEL PACK . m :_. :Oepttl`17f:Grout Seal.
<br /> I_::_ ;:L1::CAT1iODIC PROTECTION 13,.RO.TARY_ pe_a.f.Grout..
<br /> 0 171SPOSAL 0 °OTHER _ :::Other Information
<br /> .'Surface.SeaLirlstalledUMP-INSTALLATION: j.._.,..,,._�:_�. ..:,Contractor_ .-
<br /> ,.
<br /> :Type of Pump H.P..
<br /> r
<br /> PUMP, ..-JD_ State Work.Dong
<br /> HEP..tiAC.EIII�NT:_..��....--- e..—,- - .
<br /> LPUM;PjFiEPA]R:_- ,_ . . _ ._..-., , " ._ State Wack.Done
<br /> .DESTRUCTION OF
<br /> • -- Well Di -MaterialM Approximate'Depth
<br /> Deand Prgcedure
<br /> l:hereby certify hat:t-have prepared this-application andAhaflh^vwlark will be done IB,:racr-rardartceviiithriSan Joaquin County
<br /> ordinances, state.taws,;and rules and regulations of the:San a�oac' "n -ocal•Health,District w" ..
<br /> R� ... .- ffome owner,brlice+rt edagent's signature certifies the fnfIawIng :'�t:eer.ttfylhat intheperfohmffce:of.the-work-to r.which thispermlt
<br /> wis issued, l shall':notl mploy anyr-person-in such manner-as.to�ecome sublect.to-lnrorkman°S-,Compensation laws-:of,:Califomia.' .,.
<br /> Iss w-•+ �err-.-,--Contractoes=hiringor,suis-contracting-signature:certifies,the.fallowing::=rCcertity<tf cin;lheple#ormance=of=thework,•forwhichthis,:.:ri.,
<br /> s^ ... permit is issued, 1 shall•employ.persons subject to work man!s.com pensation laws of California." `., #•_
<br /> le: x- Ir will zall..for a Groull.lnspect' n, to. r In aw a•tin inspection..-.-
<br /> __Signe _ 01 - - Date:
<br /> (Draw Plot Pla n-Reverse Side). ;
<br /> o" FOR DEPARTMENT USE' or
<br /> ONLY.__ .t -
<br /> PHASE I g
<br /> h -
<br /> Application Accepted 13y
<br /> k• .:.. .. Additional Comments_
<br /> t. '.''Phase It-O rout fr1sp12etion �::r = :r_ .. Phase-111 Final-Inspection
<br /> _ _Jnspection By. _Date_ frispection.By Date.
<br /> ,,:-..,. ..�..b._--�........ ---,::..�„-----•: _� ,•�;.,,.-�..�_...,...... ..: _-,ter
<br /> Feels Due-.0 ANNUAL' ": 0 PER UNIT • ' OPER SrTE-" 0 EACH': January 8"Received By January 31: [] July T 8'Received By July-31
<br /> REM
<br /> .' ._ BASE EXPLANATION MITTA E' ,3 AMOUNT DUE" I £CKEO '
<br /> BILLING.; RE NC
<br /> DATE +'+� x, DATES REMITTED :y.MOUNT
<br /> - ' FEE
<br /> LESS
<br /> PRORATION
<br /> I
<br /> PLUS
<br /> PENALTY
<br /> r, OTHER
<br /> - OTHER 40
<br /> :; Received by Dale Receipt No. Permit:NO. Issuance Dale r Mailed Delivered
<br /> ;' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH ERMITrSERVICES" 1601 E.HAZELTON AVE..-P,O.Boa 2009 'STOCKTON,�CX�95201F-
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