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. � ;� _ •-"••••••�� ••+ �. VVIIIFIIGICas uc.ouia �,u-Jr�n-rna-raNp�iuc u�rl. ;" - <br /> 4 FOA OFFICE'aJSE:" APPLICATION #. : <br /> = {ForcNon-Transferable, Revocable,Suspendable) '• 'ti ' <br /> ENWRONMENTAL'HEAL <br /> TH PERMIT <br /> (COMPLETE IN TRIPLiCAT,E) WATER QUALITY <br /> Application iSMerebymadeic.ffiiGan Joaquin Local.HealthDistrictfora.per:mittocon struct=and/or instal I the work herein described.This.appIication is <br /> made in compliance,with:San Joaquin,County(Drdin nce No 1"862,and1herxufewand TiegulMidns-of-the San Jo uin Local.Healthbrstnct. <br /> Exact.,Site Address d <br /> Owner's Name. Phone <br /> ..._—Address :1- a City <br /> -,Contractors Nal p �g� Business Phone_. eZr--1,7 4�+ <br /> _ <br /> Contractar'S 1ddr_ess_ O :ErnergenCy.-Phone <br /> Is-Certificate of Workman's Com eftation_Ins `¢— <br /> P urance on File With=SJLHD� Yes_ 'i,• _",,:":•bIQ ."" .. . <br /> TYPE OF WORK {.CHECK): .'. NEW WELL�,M . '`,,DEEPEN:E]..r RECONDITIONE-1. DESTRUCT16IN13 - <br /> WELL"C41bRINATION ❑ WELL ABANDONMENT E3-.... OTl-1EFt fl- - _.,PUMPANSTALA24TT0I4" -IJiVIP RI PAIR <br /> REPLACEMENT - <br /> DiSTAT+iCE°TO NEAREST- Septic Tank , //`YJ'_- - Sewer tines Pit Privy. <br /> tSe,wage..10isposaI Feed " . ..Cess0001/5�epage Pit Other <br /> f' Property,line:'JJ 'PrivateDOfnestic,,We71. ;2/ Public•Domestic Well <br /> INTENDED�.USE .,a: :TYPE.DF WI=LL. ." <br /> H <br /> r©�7, INDUSTRIAL i _ OCABLE TOOL- �D.ia:of Wel]Exdavation <br /> =_.XDOME»STIC/PRIVATE-- :::' --DRILLED - - -,. --. Dia.-of,Well:Casing <br /> DOMESTIC/PUBLIC ;, ❑ DRIVENGauge of Casing _41 <br /> »�JRRIGATIOftf GRAVEL-PACK _ �-Seal <br /> 0`-CAT;I+iODIC-.PROTECTION .ROTARY .--._.. Type of Grout <br /> • _0 DISPOSAL _ 0---OTHER _ LLOther-I nformation <br /> .:O:GEOPHYSICAL <br /> `,Surface.Seal Installed By: -f z x <br /> -. 'I?UMP;lMST11Ll..ATION:,._.._. ....w:�Gontractor - <br /> Pump <br /> . ' - H.P. <br /> PUMP, EPLACEMENT <br /> r :Mate Work_-Done. r` <br />_,--h L1f114P•.REP_t11R::.. .� �*. �; :'State.'Work.Done r <br /> DESTRUCTION.0E-WELL ix'. Well-diameter - <br /> "' Approximate Depth <br /> 4'. bescribe.,Material-and.Procedure. - <br /> .,-1:hereby certify that 1 have prepated th ts:_appllcation and,tbat.the work-will-be done in"accordance with San Joaquin <br /> ;County <br /> ordinances,state faws;-and-t'ufes and"regulations of the.San,Joaquin l=ocal Health District. <br />* p w Home owner or'IIa6 ed agle WS signature certifies the fofloviring:71-certify that,inthe performarreeof"the Work for.wh ich.this permit <br /> Is:issued; I shall not employ,anyperson,in such'mahner as to�ecors+e jecf•to:workman workman's laws of California:" " <br /> ,Co9/sub-conitactingsignature�certifies-lhie-followin i,certi thatin>the e4ormanceof-the work•for"whichthis � ' <br /> permit is issued,I shall empioy.persons.subject to workman's compensation.laws of Califewin.'' <br /> I' r 1 wi It.tor""�a",Gr6utdgspection prior to-grouting and e.final._inspection. .. <br /> _ Signed.x - � <br /> : ; Title: -,. Date: . — <br /> (Draw Plot Plan on Reverse Side) <br /> F-OR.f]EPA'RTMENT.USE.ONLY <br /> . .,.CHASE I . <br />- L"Application'Accepted�By_ - Date_ <br /> Additional..Gomments: <br /> --�x" aPhase.il'Grout Inspection Phase'III Final tnspec o <br /> inspection BY Date " <br /> Inspection By C ate. -} <br /> V ea T <br /> Fee Is Due.-.0 ANNUALAL*-�Y' ' <br /> ❑ PER UNIT` ': PER'SrrE = I�.EACH January 7 8'Receiveda By�Jauary 3i. ❑ July 1 B Received_By July 31 <br /> k •REMIT <br /> -` BASE " EXPLANATION $ILLING REMITTANCE f AMOUNT DUE _. e }IFC1C>p <br /> _ DATE DATE REMITTED AMOUNT <br /> FEE I J Nl i <br /> LESS ! <br /> ,PRORATION <br /> PLUS <br /> PENALTY <br /> OTHERUA <br /> r. <br /> O7HER s <br /> i <br /> . Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> - APPLICANT—RETURN-ALL COPIES TO: ENVIRONMENTAL HEALTH PERNitr/sERVICEs 'f6pt E_HAZELTON AVE..P.O.Bim:IMA "Ycrnrrrnu rA—.1 T <br />