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--a— ••epulr Juu,1111ea rropeny gompreted BeSureTd'5ign The'A�plication:" �'"" " - � —� <br /> FOR OFFICE USE: " APPLICATION <br /> r „ (For-Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HE�kLTH PERMIT <br /> (COMPLETE IN TRIPL,I ATH :WATER,QU LITYs, <br /> Application is hereby made iothe San Joaquin Local Health District for.a permit to construct anti/or install the work herein described.This application is <br /> made in compliance wllli SAft Joaquin County Ordinance No. 1 land the rules and,Tegulations.of-the San Jo uin Local Health District. <br /> Exact.Site Address. S ��Yt erg o li City/?owp, <br /> Cg vyi d <br /> Owner's Name <br /> Address <br /> Ctty, . <br /> Contractor's Name Licens # 3�Gq�c�,// -d <br /> �J L Business Phone + <br /> Contractor's Address _� �fnergency Phone <br /> Is Certificate of Work.fiati's-Cb pgrisati6054nsura6ce on File With,.SJLHD? Yes ' <br /> No <br /> TYPE OF WORK-(.CHECK): t4EW DEEPEN ] RECONDITIONDESTRUCTION❑ r <br /> I -74,WELL`CHLORINATION -WELL.ABANDONMENT ❑ pTHER'❑ PUMPi'INSTALLATION�— PUMP RI=PAIR❑ ' <br /> REPLACEMENT❑ r <br /> DISTANCE TO NEAREST >,.Sepllc Tank Sewer Lines p <br /> �: iCPrivy..: ,. <br /> Sewage Disposal Freid Cesspool/SeQpage Pit ( Other-- <br /> Property Line - ;y Private,.Domestic Well ':-:°t'uhlic Domestic Well r <br /> INTENDED USE -_TYPE OF WELL <br /> ( ❑ INDUSTRIAL g CABLE TOOL -Diaof Well Excavation <br /> 41 r .:. - - , <br /> . ,. <br /> ,DOMESTIC/PRIVATE :❑ DRILLEDr bio. of Well Casing <br /> ❑.DOMESTIC/PUBLIC; ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION_ ❑ GRAVEL PACK Depth of Grout.Seal L5 w <br /> i - <br /> ❑ CATHODIC PROTVOTION' ❑ ROTARY <br /> ❑.l]ISPOSAL ❑ OTHER Other Information <br /> ❑ 'GEOPHY51CAi Surfa <br /> PUMP tNSTALLAT1ON ,,.,�.; Seal Instat+ei <br /> Contractor= c = Se _- <br /> 1 Type of Pump <br /> PUMP REPLACEMENP ❑ State Work Done ' <br /> PUMP REPAIR: © State.Work Done _ <br /> DESTRUCTION OF WkLL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> ! hereby c61111y that I have prepared this:application and that the work will be done in accordance-with San Joaquin-County <br /> ordinances, Mate laws, And rmfes and reguiations:of•the-San-Joaquin Local Health-District.., <br /> Home ower at liceneedagent's signature tertifies-the-fotlowing:".I certify:that.in the.pel#ormaambtthe:work for which this permit <br /> is issued, V11hall not em <br /> ' to an , " <br /> p y; y person.• n such manner'as,:.to become svbject.to'workman's compensation laws.�of California. <br /> --Cantraclol <br /> ring or Buts-contracting signature certifies the following,"trertify'that in-the'performance of the.work.forwf ich this <br /> -permit is issued. I shall employ persons subject to workman's n s compensation laws of California." <br /> Iwcall (at a Grout Ins ection prior t <br /> oegroutfng and a tidal inspection. <br /> Signed X _ <br /> Title: Date: <br /> >` (Draw Plot Plan on Reverse Side) q 4 <br /> i. <br /> FOR DEPARTMENT USE ONLY - <br /> -PHASE I <br /> Application Acceptod By—. �r l6 moi' <br /> Date <br /> tea, Additional Comirnoh►s: <br /> t phalli f1 Grout Inspection Ph se III Final fn ection <br /> Inspection By' Date, r <br /> Inspection By pate jp <br /> - <br /> Fee Is-Due: ❑ ANNUALLY `PER UNIT "' ❑ PER SITE ❑ EACH ❑ Januar 1 &Received B Januar 33 <br /> -- Y Y Y ❑,.'July 1 g Received By July^31 - <br /> BlLL1r+IG REMITTANCE $ REMIT <br /> ' BASH EXPLANATION AMOUNT DUE - <br /> _CHECKED <br /> ATE) DATE REMITTED <br /> FEE �S'( f��rll U AMOUNT <br /> I LESS G " <br /> PRORATION <br /> .PLUS <br /> PENALTY <br /> ' OTHER <br /> OTHER <br /> A2 9 7 <br /> Received by Date Receipt No. Permit No. Issuance Date aeled DetiveressL �J ' <br /> I APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P� Boa 2009 STOCKT6N,CA$ <br /> i r� . _T _ 5201 <br />