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EOROFFICE.USE: �. APPLICATION _F
<br /> .."
<br /> f - ._„(Far:Nan-T'ransfer6ble ,Revocable, Suspendable)
<br /> °1 Lpj° ENVIE IRON MENTAL HEALTH=PERMIT .
<br /> (COMPLETE 1N TRIPLICATE)
<br /> " • fApplicatiorl'rS,fteteby.madetotheSan Joaquin•Locall iealth Dlsirlctfor.a-permit'> .constructand/ar;irastadthework herein described.This application is.
<br /> "matle in cornpliande'.+tiith.San l:oaquin' asirliy't3Fdi axtce No't$f�2aand the,rul 4ricf;regi?latiorns7of,tha San Joa[ui ��I'Heall�h inct
<br /> - -Exact-Site,Address, /] I r
<br /> fi r6�UC l'�,A 1 P.honE
<br /> Owners Name. . aha _
<br /> Address !I O „A/ / SS'awd to�✓e .l _ :City, - -
<br /> _._,Contractor's.Nafne:, R ^ License#':� �7`��' 'Ruslness Phorao
<br /> r; , Ernergency'Phoup' ,
<br /> CorltractQr_s_Addreas_ '
<br /> is.Cerfificate of WOrkTnan s Compensation tnsvranee- n.Flfe Wjtb7-MUHD7. tYes ” •` ".?..: N� T `"
<br /> TYPE OF WORK (CHECK) tIV
<br /> - NEW ':y ',E}EEPEIN RECONDIT A❑' `DESTRUCTION {
<br /> CRLORIN;ATfON& ` WEL1"AB?kNj1 OfliMENT ❑,>7. DTH i fly'... PL%W INSTALLATION❑ PUNIP•REPAIR ":." ` y
<br /> REPLACEMENT❑
<br /> -DISTANCE TO;NEARI=ST }Septic Tank
<br /> _._._.•; ewagefllsal Field Cesspool/Seepage Pit ., '°•:`Other--
<br /> 1 _.
<br /> , _. :' . �.... .- „;_,�. �a,:,•P.roperty L.1ne., -
<br /> -;�Pat -' e11 - Pu-
<br /> b!is�DomestIc�
<br /> VeH •
<br /> INTENDED-.USE TYPE.OF.'WELL
<br /> ❑':4NDUSTRIAL '❑.7ABLETOOL- ~Dia- of.Well Excavation
<br /> I :Dia.,.of=Well:Gasin
<br /> °�EII•ilOMESTIG RIVATE. I]:i f}E3'1L1ED 9
<br /> ❑:DOM'ESTICIPUBLIC ❑.DRl1 N auge of.Casing }
<br /> G
<br /> :IRRIGATION, ❑.,.RAVEL PACK depth'-of.Grout Seat
<br /> QrOATHODIC.i?AOTECTION
<br /> 0..R0TARY - L._. "°,TYPe of Groiit.
<br /> 5 ❑DISPOSAL: C] .OTHER =.Ofher information ell
<br /> I LI.GEOPHYStCAL Surface-Seat,•,Installed'By:
<br /> P.IJMi'�i+ISTAt=LATtON CQr?iractor_ 4e..
<br /> r ..: • k
<br /> *.. Type of:Pump
<br /> ' Pl1MP:REP.LAC.EMENT: '..,. n;State..WOrk:Darie
<br /> -State -Done
<br /> v. :P.UMR4REPAIR: a,i=___Aa �. -. .
<br /> 91
<br /> _Approxirnate_Dppth
<br /> ..DESTRUCTI.ON-Ot=:W.EI L .Weli.J]iamater.,
<br /> , . _.
<br /> ^µ ,•_ . Describe,Maferialarld;F'roeedure.
<br /> �..I,-herte y_certlfy-that•f-have prepared�this.appiication.,end thatAhe'-work will be done:.in=accordance-with+San Joaquin_CouMy,•.= r .
<br /> ;•z r",1
<br /> r-Ordinances,statie'taws;and,-TvAes-and regulations olrAheSan.Joaghin;ltocal Health
<br /> �: s.�. Biome awrierar,lic r3serl-agent's signatoc+a certitles°the:laliewing:,"I-icertifythat4n-the pe-formanceof.thework ter nrhict';thisipeTmit 7
<br /> .... •i5.Issued:-.,Ishall:-notemploy:-any,personirr'such,.manner.as,to- ecomesubjectilo-workmansr=pensatiorraav¢s'ioUt sfifornla _ s
<br /> 1 . .,..`:Canlraclats,hiriilgor.sub-contracting°sigoalureceitifiesttt3elollowing:•"Iceciify3hatin.tine:pe ormaruleof�#lewotic:toraukuciatt3is.,. ,
<br /> i permit is issued, 1 snail employ persorlssula;eCt:to tivorkman's:compensalion laws of Califgtxlia:"„». . '
<br /> Grout.lnspec p 'or io-gry gya ,a final.inspeciion. . •eti_ _ _, :.�, tti. _ .� : ;
<br /> •' ;rTtle' rse Side)•(' Date
<br /> - {DraW;•Plot Plan on-Reve e) r,
<br /> =x. To R�,V PARTMENT USE ONLY ..
<br /> � ± -PHASEI
<br /> r Oate�
<br /> Application Accepted By
<br /> Additional COmments.
<br /> r Phase-, i! =ina,lnspecli
<br /> on
<br /> Datelanspet;tios Phase 11 Grau
<br /> l . -Inspection-By• ” ,Uate- Inspection By .
<br /> 'Fee IS Due:-❑ ANNUALi:4 r'.`::fl`.'P.ER UNIT- s"-'[ PEA SITE :: ❑ EAC1i. ❑ January 9 &'Received By"danuary 31 .-�, ❑-.July 1 h jived By-July 31
<br /> __ B-MIT
<br /> "BASEI EXPL'ANATiON -BILLING REMITTANCE � : 4 � :=AMOUNT.DUE, '>��"11=CKED o _r
<br /> DATE DATE REMITTED AMOUNT l
<br /> -. -
<br /> ata FEE
<br /> LESS x t
<br /> ((> PLUS
<br /> PENALTY
<br /> OTHER
<br /> �., OTHER
<br /> -7-6 / ..
<br /> 4 - 'Permit No. -lssu nce'. ale Mailed Delivered -
<br /> Recewed by : Dale Receipt No.
<br /> c STOCKTOH,CA 45201
<br /> APPLICANT—RETURN ALL COPIES•TO:"+ENVIRONMENTAL HEALTH PEi1MITISERVICES 1601 E.HAZELTON AVE..P.O.Box 2009
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