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<br /> FOR OFFICE USE '.:•APPLJCATION
<br /> - s(Fsof Ion-Transferable,Revocable,Suspendabie) p
<br /> �> T'E'NVIR0'NMEN_TAL HEALTH PERMIT
<br /> (COMPLETE IN TRIPLICATE)•± WA's R QUAWY .
<br />-;a.,Application-is-herebymade¢p the San Joaq.uinl:oval.HealthDistrictfor.apermit:to lnswctand/or install.thework herein described.`:This.application:is
<br /> .
<br /> made in compliance with San Joaquin."Coun.ty Ordinance No. 1862 and.the-rule"nilt t gulations of:tf1e San:Jo�wl Local Health-District."'.
<br /> Exact Site Address 1#f � 6r L" -
<br /> Owner's Name 5 J1,-r,I Phone
<br /> ...,Address ,,. p6rAt ,,/ City 0 fr
<br /> ContractoT•s-.Name: ,. q._.,.Qrf�+�a+llkih ,s. Licensdit, -q,04~ Byzin e t
<br /> 'a Contractor's-Address._ �_. / !,
<br /> �merger}cy.Phone _
<br /> Is Certificate'ofWork man's,Compensation Insurance-on Fife With SJLH1[37 -Yes �rNo-.a
<br /> TYPE OS WORK (.CHECK):- NEW WELL Wo' DEEPEN:❑ - RECONDITION❑ ::> EST3�LiC C10
<br /> WELL CHL(JRINATICJN CQ''-;.WELL'.,ABAI�IDONMENT Q OTHER Q PUMP lt4STALLATI;Oltr - y� n, ,tP.UMP-,9ERAIR❑
<br /> REPLACEMENT❑
<br /> DISTANCE TO NEAREST: r Septi.e Tank. [- Sewer titles Pit Privy �+
<br /> -j Sewage Dis osal'Field.
<br /> � . ....--- • Other
<br /> Pperty Line Private Domestic Well s Public Domestic Well
<br /> INTENDED.-IJSE TYPE OF WELL
<br /> ❑.INDUSTRIAL ❑ CABLE TOOL ,. DIa, of Well Excavation_; «�-- „•.,.�
<br /> ❑. OMESTICIPRIVATE :; ; ::. ❑ DRILLED_ _ .t?Ia, of Well Casing- =r..�
<br /> DOMESTIC/PUBLIC-. Gauge of Gas
<br /> g 9 - _
<br /> 13:19RIGATION ❑ GRAVEL PACK Depth`tl# Grout Seal _
<br /> ";D CATHODIC-PROTECTION 0090"TARY'_ _
<br /> Type of Grout
<br />°.r❑ DISPOSAL ❑''OTHER_.. . -Other.Information
<br /> C1 GEOPHYSICAL. Surface Seal lnstaljed 8y, �v 1
<br /> PUMP.INSTALLATION:_- ti Contractor,
<br /> L Type of Pump �— H.P. of v
<br /> :PIMP RELACEM.ENT; . r = ❑'State. Dope : «•• tst .,I > rnarn r.; tnrr" -K t r at .r.
<br /> - .r:. - t
<br /> PUMP REPAIR _„e..:.._. } ❑ State..Wnrk;Dcfne
<br /> :DESTRUCTION OF.WELL .: F :,Well Diameter r p-_- a 1
<br /> p oxrmate,Depth.
<br /> Describe:Material and Procedure
<br /> 61t I,hereby certitythat"I.have preparedsthis:application•and that the,Work;witt-be-4done-in accordaneewith San Joaquin.County.. n�=.;;
<br /> „ ,ord,inances, state laws, and rules afid,regulations of-the Sart Joaquin Local,Health.District,
<br /> :• ^r�r I�
<br /> s.:� + �. ,a ,ti.grtte er_�r nsed:age t:8;sfgneturee Certifies the_fotlowfng."I:certifohat n-the pertormat'ice,of:tile work�tor_wbich4hi&pwrrl t le
<br /> ti is.issued,4,shall not employ any person in such-manner-as to become.subject to workman's compensation laws zf:California." ,r
<br /> F,�:►3 w:� an1raetor'si3iring or sub cocitracting signaturecertifiesthe tol#owing:ftcertify:that in the performam.ee of:the.wo''rk4o*wtWi-ah2his iL -• I
<br /> ;.i*Perm itis issued;7 shall employ persons subjL'Gt;to workman's compensation laws of California.""
<br /> r. � s.4;tgil#=Gall for a G out=l tion prior.toV4auting and a�4lnal inspettlon: ,r r r� ?�r. rr<, :;a,* :r ,:.,;•, .,�.•,;;;
<br /> t �F
<br /> f
<br /> Signed X. _ ,-:s .; Tiltte. _.l Date?�"`• �� "-�'�� _ .. - -
<br /> (Draw Plot.Plan on Reve O Side) ,{
<br /> �.z PAFORp RTNE T USE ONLY
<br /> i
<br /> PHASE I y i Date
<br /> _Application Accepted B
<br /> .Additional Comments: 1�7i
<br /> Phase 11 Grout inspection ,, a . :Phase 311•Fina! Inspection.:, " i T
<br /> Inspection By _ Date JftspeCtion By Date _
<br /> Fee 1s-Due: ❑ ANNILIALLY ❑ PER UNIT ❑ PER SITE n;r ❑;EACH ❑ January 1 &Received By Jaquary31. ❑ July 1 $Received By July 31-;
<br /> P REMIT
<br /> BASE EXPLANATION BILLING REMITTANCE E l AMOUNT DUE 'CHECKED
<br /> DATE DATE REMITTED AMOUNT
<br /> FEE ¢0 /}
<br /> LESS 3,Q I
<br /> PRORATION
<br /> F' PLUS
<br /> PENALTY
<br /> OTHER
<br /> OTHER
<br /> ? .�
<br /> Received by Date - No. Permit No. Issuance Date Ma0ed eiivered
<br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON.CA 95201
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