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r !'iy!}i114Pi1Vlla ■1111 lac 1V4caasu �xllcll VUVraac>Jrlul/oll' MJVIrcacaa +caauc Ivva, a laic1-arrl4oaaVls. , . <br /> FOR OFFICE USE: APPLICATION ' r <br /> (For.'Non-Transferable+,"#V coble,'Suspendable) <br /> ENVIRONMENTAL-HEALTH PERMIT. <br /> I (COMPLETE IN TRIPLlCATEj `• WATEA OULAY � •' '' <br /> I Application is hereby made to the SaW.JoaquinLocal Health District fora pefrrtltlaconstruct and/or install thework herein described.This application is <br /> made in compliance with San Joaquin CountyArdlinance No. 1862 d the tlilras and regulations of the:San Joaquin Lo ai Health District- <br /> .Exact Site,Address•�� ��� °E.u/v�4/v �� __._-____ GGity/Town: .�s��a ,ami <br /> Owner's Name'• ��N::` r ___� Phone <br /> Address n,6,g — (iity : $eak," <br /> Contractor's Name - License Hf?.�?I/�/. Business Phone <br /> Contractors Address - Emeigenby Phone <br /> Is Certificate of W&kman's Compensation Insurance on File With SJLHrj? ' Yee_ X No ` <br /> r TYPE OF WORK(CHECK NEW-WELL& " DEEPEN`11! RECONDITION O DESTRUCTION❑ <br /> f WELL CHLORINATION ❑ ' ;WE L'L ABANDONMENT ❑`- OTHEA a..'. PVJMP -INSTALLATION ❑ 'PUMP REPAIR❑' 41 <br /> REPLACEMENTf <br /> DISTANCE TO NEAREST: Septic Tank /S� Sewer.:Linee :Pit Privy - <br /> Sewage Disposal Field Is<0 Cesspool/S"paged?it - — .Other <br /> Property Line/6 lf.:'Private'Dom estic..Well Public',Domestrc'.Well � <br /> INTENDED USE TYPE OF'WELL <br /> ❑ INDUSTRIAL .. C'ABLE TOOL ,�"Dla. Of Well Excavation <br /> r <br /> P(DOMESTIC/P.RIVATE ., ❑ DRILLED Dla.'ol Well.Casing <br /> ❑ DOMESTIC/PUBLIC '<` ❑-DRIVEN Qauge of'Casing CIS <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal "50 , <br /> ❑ CATHODIC"PROTECTION ZROTARY Type of Grout', z FooEnr f _ <br /> ❑ DISPOSAL- ❑ OTHER, .::. Other Information <br /> ❑ GEOPHYSICAL 1. Surface Seal installed By:. Qt4 <br /> PUMP;,I NSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ., .:.v.,. ❑ State Work Done <br /> PUMP REPAIR: v. ❑ State Work Done _ <br /> DESTRUCTION_QF WELL:"' Well Diameter °._....-. Approximate Depth <br /> Describe Material and.Procad;Ire <br /> I hereby-certify that I have prepared this application zncl that tfie-woik Will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Juaquin Locltl Health District.— <br /> Home owner or licensed agent's signature certitles the following:"I certify that in the performance of the work:forwhich 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%hiring or sub-caftbactfng signature certifies the following:"I certify that in the performance of the.work for which this <br /> permit is issued,.l shall:employ persons-cubjectJo workman's compensation.laws of:California." <br /> I will call for w-Gro I ��_r <br /> grvuting and a finalSigned X . Title: A0 OE/y L Date:,.2L? 7&� <br /> (Draw Plot Plan on RevelTs <br /> OR"1]EPAATfIAE T USE ON Y <br /> PHASE d _ r� <br /> ` Application.Accepted By v _ Date7 Z <br /> Addition Comments: <br /> 10 <br /> J` a II.Grout" pection f"y Pha 11 inal ins ection =+ <br /> . section By V ate f a� Inspection By Date 12-111 <br /> Fee Is Due: D'ANNUALLY PIER UNIT°`•.:"-❑ PER SITE ❑ EACH ❑ January I &Received By January 31 ❑.July i'&Aeceived By July:31` <br /> ... ..sz - _.,<,-BILLING REMITTANCE <br /> ,':�' - $ _ REMIT <br /> BASE EXPLANTATION AMOUNTDUE <br /> DATE - DATE REMITTED 'T ~CHECKED <br /> AMOUNT <br /> FEE R <br /> LESS <br /> j PRORATION I <br /> I PLUS <br /> PENALTY <br /> 'I <br /> OTHER <br /> OTHER <br /> ? 9/� issuance <br /> Received by Date Receipt No. Permit No. - 'Date Marled Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P-O,Box 2009 STOCKTj I�.�A�95201 <br /> . - IF67Y' <br />