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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APeMCAT{ON <br /> (For Non-Tr sferable, Revocable,Suspendable) / r�7 <br /> p <br /> ENVIRONMENTAL HEALTH PERMIT <br /> { (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This.application is <br /> made in compliance with San Joaquin�C)unt mance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address <br /> ,��p /� . �$�.� City/Town <br /> a Owner's Name Ug- 40 Cf/19 AL Get/ __ Phone <br /> Address City <br /> Contractor's Name NrCA W&1-4 n4-di-license 2-3BusinessPhone <br /> r Contractor's Address x2000 AJ. eSQxal�l�'f n(arf �J Emergency Phone �3 If9E <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK):' NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONSE+ PUMP REPAIR CI <br /> REPLACEMENT❑ 'f ' <br /> DISTANCE TO NEAREST: Septic Tank. VN IF Sewer Lines VVAJ AC Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit /00 { Other <br /> Property Line Private Domestic Well / Public;Domestic Well <br /> r INTENDED USE TYPE OF WELL f ; C% <br /> ❑ INDUSTRIAL .CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing Rl <br /> t ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing a ' <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ,. <br /> ❑ DISPOSAL ❑ OTHER Other Information 7T� <br /> ❑ GEOPHYSICAL /�_ / S,Urface Seal Installed By: LDS►LL rc'hCr j <br /> i PUMP INSTALLATION: Contractor /"!}�fi--Za clP W,91-L- nRr !1 i A.1 <br /> 4 Type of Pump a lrrr, a- Y` F H.P. 3 Ip• <br /> PUMP'REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done 4 W <br /> DESTRUCTION Orliill1Nell Diameter _ "'�� """ Y Approximate Depth <br /> DescribWMater-ial and-Procedure' <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 /> t Home 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:A certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California. <br /> I -'II call for a Grou nspection prior to grouting and a final inspection. <br /> Signed X Title: �---_&%-JV --� Date: <br /> 7 o2S=-7 <br /> v (Draw Plot Plan on Reverse Side) <br /> ORD PARTM NT USE ONLY <br /> PHASE 1 f <br /> Application Accepted By "" Date 77' <br /> Additional Comments: - <br /> Phase II Grout Inspection Pha a III Final Inspect' n "s. <br /> { — .. �l <br /> �- t- Inspection By— - Date- - Inspection_By to 5;,- <br /> Fee <br /> -Fee Is Due: ❑ ANNUALLY ❑ PER UNIT IX PER SITE ❑ EACH ❑ January 1-&Received By January 31 ❑ July 1 &Received By July 31 <br /> 4. REMIT S <br /> . - BILLING REMITTANCE $ I <br /> BASE EXPLANATION DATE If DATE REMITTED AMOUNT DUE CHECKED i <br /> AMOUNT f <br /> FEE 91 <br /> LESS <br /> PRORATION - <br /> PLUS <br /> r PENALTY - <br /> FF OTHER <br /> c OTHER <br /> 72- 5 5 i <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> p J <br /> „APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES �,1601 E.HAZELTON pVE.,P.O.BO■2009 $TOCKTON,CA 95201 <br />