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FOR oFFI USE: _ APPLICATION ` <br /> =,(For.-Non-Transferable, Revocable, spendable) r' <br /> J <br /> ` ENVIRONMENTAL HEALTH'PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER IVALITY <br /> Application is hereby made to the San Joaquin Local Health District for.a permit to construct and/or install the work herein_described.This application is <br /> •made in compliance:with San Joaquin'Coun rdin nce No:.-.1862-and the-rules-iand regulations'of the San.J.oaquin Local Health,District. <br /> Exact.Site Address, o City/Town - <br /> owner's Name Phoge..,�/XS� -� <br /> ..Address, .City <br /> -_.Contractor's Name �S1,q�r �. Licerpe#, •. — —Business Phone �-- <br /> 1 <br /> -.Contractor's Address_ ";W _ •=.EmergePcy ho[I.e <br /> F <br /> Is-Certificate of,Workman's•Compeiisatio0_Insurance On'T4l#14Nrth ,JLHD? .:: Yes <br /> _.TYPE OF-WORK(CHECK):. NEIN -WELL❑ '-'DEEPENRECONDITION DESTRU3CTI003' <br /> WI=LL,CHLORINATION.� .,W&Lr ABANDONMEf+IT Q" OTHER ❑ =- 'Pi7iVIP TNSTALL'i4Ttl7N 'r" :PtJNiP REPAIR❑_. <br /> REPLACEMENT❑ <br /> "'DISTANCE TO,NEAREST:r.--r -Septic Tank d Sewer-Lines Pit Privy . <br /> 6ewage Disposal Field �7_/ Cesspool/Seepage-Pit Other "y <br /> . : ert Line <br /> p y. z-Private Domestic We11 Public.Domestic Well <br /> "Pxo <br /> INTENDED-USE S "::TYP _.DF.WELL -. V <br /> .1 INDUSTRIAL "<`. -:'0%CABLE.T—OOL- Dia.-of Well Excavation _ <br /> 'n:DOMESTI.0/PRIVATE- .. ;v,:,-= _.:,� DRILLED .Dia.,of.Well.Casing. <br /> ❑ DOMESTIC/PUBLIC _i ❑ DRIVEN ....-.:Gauge of Casing ` <br /> �.IRPIGATION _ :. ❑,GRAVEL PACK :D.epth,of Grout Sea] <br /> ❑ CATHODIC PROTECTION .ROTARY. .Type of.Grout <br /> ❑:DISPOSAL _❑ OTHER_ . Other.-Information <br /> .:-.:❑:.GEOPHYSICAL Surface,Se I Installed B. <br />,...._;PUMPINSTALLATION: - <br /> Type of Pump.SU /1i.. l��e/ <br />_. . -PUMP REP,LACEEM.ENT;_,. .., ©, State Work Dane <br /> P_U:MP-.REPAIR:.-. _ �O_State Work Done - /. ..... <br />'f DESTRLICTIGN.OF.WF_LL:- :, _Well Diameter--R n Approximate Depth !•�� � , <br /> - -Describe.Materialan&Procedure, .-w <br /> - ._... . 1 hereby certify-that dnhave prepared this.application and:thatWwwork will be done in-accordance with San-Joaquin County <br /> ordinances, state.ilaws,,;and Tules and regulations of the Sar ,4oaquin.iLocal Health District. <br /> 46meowneriir.licL-ftedagent'ssignature cectifiesthe foflowing:;'iA aertifythatintheperformanceaofthe•work-for:whichthis.permit __J <br /> issued,-I shall�not.em -to <br /> p yan y persorr#ln:such:_manner>as.to-become:subject to workman's compensation'Iaws of California." <br /> Cantraclol's hiring•orsub-Contcacfir}g;signature aertilies.the Mllawing: ;I certify.that.in the pl r#ormance of-the.work far which this <br /> permit is issued, I shall emploY.persons subject to workman's compensation laws of California.". <br /> I ill call for a-Grout Inspection-prior•to_grouting and,a final inspection. .. .. <br />_-L—SignedX Titte: Date:` <br /> _ C <br /> (Draw Plot Plan on Reverse Side) <br /> FOR:.DEP RTMENT USE"OftLY, . <br /> PHASE I "} <br /> Application Accepted By *^^ Dafe. <br /> Additional Comments_. <br /> -Phase.'H Grout Inspection ::sf h se-111 final 1trispection ' <br /> 4rispection By. _Date Inspection By ✓� pate.. <br /> 1 Fee Is Due:[] ANNUALi#,`r"".fl T'. HLlNI7 "'–O PER SITE'- ❑ EACH 'O-January 1 &'Received By January 91I� DI;July 1 S Aeceived By July 31 <br /> 1 BILLING_ REMITTANCE S REMIT <br /> BASE EXPLANATION AMOUNT DUE'ir: 1iECKED <br /> ATE 17ATE REMITTED AMOU <br /> btT <br /> FEE 7 -79 . <br /> LESS <br />' PRORATION <br /> PLUS _ <br /> PENALTY - <br /> OTHER <br /> OTHER <br /> -)a 7 <br /> Received by - Date _ Receipt No. - Permit No. Issuance Dale Mailed. " Y Delfv red <br /> APPLICANT— ETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTOFtJ)5201 <br />