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FOR OFFICE USE. APPLICATION J
<br /> :*(For_Non-Transferabte 'Revocable,Suspendable)
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<br /> ENV[RONMENTAL•HEALTH'PERM IT:. ...
<br /> "WATER QUALITY
<br /> *e CoMp.LETE IN TRIPLICATE) ,
<br /> Application is hereby-made to-the Se(mloicluimLocal Health Districtlorapermit toponstruct and/or install the work;�.eteindescribed.This application is
<br /> ` "4•p'a`te in compliane&.with-Sahdoaqu"Iri:CdjUrity!Ordinance`Nci t862,et•+.d,the:-.ruies and,-regulatibns of-�the.San:.Joaquin;Local;Heatth'_Disttriict. '
<br /> :. d Cltylnw�t
<br /> :Exact..Site Address-
<br /> Name bz X,
<br /> G' Phone
<br /> _.Address _. City
<br /> 1 : . :'Xontractor's.Name fAn&4. L'icense,#1 79- ,Business.Phone
<br /> }
<br /> ,r.�":rontractor's.Address>: r,rrw. Eme.r9Qncy l'he
<br /> F� -_ is Certificate of IIVo�ktnan's Compensatioi7_insur�nce on;Faf , Ith.SJtiiDh ::,,Yes :,z :? :.L l2ar •. r, .-. ;, .s c. ,•v-ti-
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<br /> �R y.TYPE OF WdFiK jCFtEGK) ANEW WELL 0 ' '-DEEREN� . RECONiDfTt6k CI �IESTRCiCTIDts��
<br /> b' lNE1E<'CFILOI�iNATfON-�, s WELA:4,AbANQONMENT� .'" OTHER � ;. ��VSTALLi4TlOtV�� PUMPREl?AIA�",
<br /> :REPLACEMENT© ,_, - - --.
<br /> o' =:DtSTANtE.TO NEARE57,"_ Septic:T.ank Sewer.Cirie5 + PifipriWr''n
<br /> r
<br /> I : Sewagg.i)tsptssai FieldCesspool/Seepage Pit; Others
<br /> ".Property.Line
<br /> f'ri+rate,E}omestic.Well ��lic.;Damestic Well
<br /> INTENDED'USE
<br /> ❑'iNQUSTR9AL QCABLE TOOL- :: ia...nf Well-Excavation
<br /> DOMESTaClPAIVA7 i 4d' ILLED f�ia..of;V�eILC:asing:
<br /> I ",DOMESTIC/PUBLIC.:,' U.-DRIVEN ._.Gauge of.Casing ,
<br /> t
<br /> ❑:,IRRIGATION �-�AAVE�'PAC_•K< .. . _ .'Depth of Grout Seal,. lid
<br /> =❑;CiATHODIC.PROTECTION -;-,.:0_rR0TARY
<br /> -C ,.DISPOSAL .0 OTHER, .'_:Other.lnformat.ion_
<br /> ' `'JD.:'GEOPHYSICAL "' —Sur—face,—Seal,Installed..,By:
<br /> �. .- _p:UINP;IN$3ALIATWN Cq.ntractor m � C
<br /> Type of Pump f H.P. /
<br /> : PUMP REPLACEMENT :State Work D.orl --
<br /> :.;; POMP REFAffi; i. ... k:�:Siate•,INo.>slne_ .,.7
<br /> •
<br /> RESTt31JC?l.C3N_OFYYELL: ---= -..--__, INell.Diametec..� �Ap.proximale.Depth, ;
<br /> -. .�.--ADescribe.,Material:and:Procedure
<br /> t;hereby.certify;thatf:,haveY prepared this application and-ihat7he�work-will'be done,in accordance,with,San-Joaquin County
<br /> ordinances;•stata#aws,'anrdTurfes and�regutations of the San,:itoagt�in.;Loca1 Health.,District-.
<br /> I a .��; ,�Flomeow#ter��Ficeti'Sedag�nt's-�ig�elufa.t�rtities#he;to.Itavltrng:'J:cern#.y.ihat�iriihepeiormarrce.Qttheat�arkforyuhlchthis:permit, .
<br /> -is%issued l-5hall plot employ anyaprmon iii;suchmanner,as to-beicome subject=to workman s�Gornpensation lews.of California -
<br /> ' + ,M,�:;"�£ontractoes-.hirng.oi•Aub=contracting;signature::certdies��Ji)lt-owing;':'I,certity atm,theta ors�aar�.ce,of.thew• r ;torwhichthis:,
<br /> -permit is issued,=!shall:employ-persons"subject. -lAws:Of.,Califoain.�._-
<br /> "cutin atid-al.1inal inspection, �'- = _ -- - ,.;
<br /> .:.1-wIIf catl.taT '" Tout-lnspe is Pri 9 9' p r ;- ::. p N
<br /> MSI neli.X TTitia:_wl Date:
<br /> t g - Draw lot Plan on.Reverse Side),
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<br /> R DEPARTMENT.USE ONLY
<br /> :PHASE 3
<br /> D
<br /> —Application Accepted.Sy -
<br /> '
<br /> at
<br /> -:Additional Comments:
<br /> Phase 11 Grout tnspettion pection
<br /> ..::._- .inspection-By :'`.. Date - _ ` Inspection..By - 1 E' InsDated
<br /> 'fee IS Due: 11 ANNUAtt'd +' " ❑ Pt=R'UNIT '+�d:Q"P8fl-51TE�"' ❑ EAGFi ❑cJaniiary'1&`ReceiJed'By-Jaru�ary 3t �-.)� Jalyr:.1 6 iiecelved 6y;July,37
<br /> - --
<br /> REMIT
<br /> BASE EXPLANATION a3tLlINGs REhAITTJ3NCE....,..,,.: $ M U iiEG_KJ 0 ^'
<br /> B DATE' GATE REMITTED v.. OUNT.D E
<br /> _,,._.. *AMOUNT
<br /> I FEE
<br /> E LESS '
<br /> # PRORATION
<br /> i! PLUS - -
<br /> PENALTY '
<br /> OTHER
<br /> ,i:+•s•i OTHER
<br /> 9 4.6
<br /> Received by Date - - -- Receipt No. ... - '.-Permit No. - - �� Issuance Qate Mailed - Delivered
<br /> ;,. APPLICANT—RETURN ALL.COPIE'S TO: £NVIRONMENTAL•HEALTH PERMITISERvices, 1601 E.HAZELTON AVE.,Ptp.Box 200 STOCKTON.CA 95201
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