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FOR OFrICE USE: rarri.rvr+r rwa� �,- ` <br /> (For'Non-Transhrable, Revocable,Su"ridabla): ' <br /> j <br /> ENVIRONMENTAL HUAL.TH PERMIT <br /> ACOM Application IsI a eAiPLICATE) WATER QUALITI'. <br /> pp by made to the San Joaquin Local Health Districtfora permit to Construct and/or install the work herein described.This application is <br /> .r g q -- <br /> made in compliance with San Joaquin Cou�t Ordinanc�No. 18612�di e rules and regulations Y��thretSan Joaquin Local Health District. -� <br /> Exact Site Address <br /> Owner's Name �\ � L:-. Phone `��-,�C�x� . <br /> .57 <br /> .h,_F. _.. City <br /> Address__. <br /> Contractor's Name :_ ,JL�L ..r.� ._`. GAS . ___- License <br /> Business Phone. <br /> Contractor's Address. '?, Emerg ancy Phone -----_- _. _ -- <br /> Is TYPEtOF WORK CtiECKificate of s CompensationNEWWELLInsuranDE�p��e❑With SJLHD^ '(es__�(,� __ - No _.---=---- <br /> ( I RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION 13 WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR 13 :- <br /> REPLACEMENT❑ ... - <br /> DISTANCE TO NEAREST Septic Tank 1OZ-1 Sewer Lines Pit Privy <br /> Propertyge Disposal Field Private Domestic Well P20 $p}al See Public ltDom - Other <br /> - P 9 -- <br /> Domestic Well --.- <br /> INTENDED USE TYPE OF WELL , <br /> L ❑ CABLE TOOL C`ia.of Welf Excavation 1L <br /> ❑ INDUSTRIA ll ie <br /> DOMESTIC/PRIVATE © DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> • IRRIGATION GRAVEL, PACK C;epth of Grout Seal <br /> © ( Ai HOOIC PHO L F f-,T ION 140TAHY f ypp of Grout - <br /> ©DISPOSAL ❑ OTHER Other information <br /> ❑ GEOPHYSICAL. Surface Seal.installed By <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump I LF <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done Approximate - Y i <br /> DESTRUCTION OF WELL. Well Diameter.: .. . __ -- _ ___.._. Depth .._.;�_ <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the Work will be done in accordance with Sar? Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local health District,: <br /> Homeowner or licensed agent's signature certifies the following:A cortify 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:"i certify that in the performance of the work for which this <br /> Permit is is;r,ur.rf, f shall crriploy persurls,Moet to workm;vi':, a+rriptinsation laws of CalifoinlA <br /> will all for a Grout Inspectio or to grouting and a final Inspection. <br /> Signed X241t.l4 Ic Title: ��.. _� ..... . U X11 C Date: <br /> (Draw Pig( Ian on Reverse�e) <br /> FOR DEPARTMENY USE ONLY <br /> :..PHASE I <br /> Application Accepted Ely ���cxxx �/"t�- Dale . <br /> Additional Comments: . .. -. <br /> j.Phase ti rout Inspection Phase III Final Inspection <br /> Inspection By 6971*v.. --- .r Date-�� 'L' Inspection By.:._-_. . - .#_60' Date <br /> ;'cti 5!I L. ❑ LAC!i ❑ Januar 4 3 Received By Januar- y1 ❑-joy 18 RP.Ceived By Jury 31 <br /> Fee lS Due: 13ANNUALLY Eli PFR t�NIF - - ❑ Y Y <br /> _ ---- ._ <br /> REMIT <br /> RASE EXPL.ANAr€r}N i. - till.t!N1;; 111,M1STANCE $ AMOON1 WE CHECKED <br /> _ DA)G PA 11; i REMITTED - 'AMOUNT <br /> 00 <br /> . r LIS <br /> PISUMA I ION <br /> PENALTY <br /> OTHER I <br /> OTHER �.. . <br /> M40 1l3h_a-Received by Date Receipt No Permit No Issuance Date Maiiect Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT SERVICES - "1601 E.HAZELTON AVE.,P.O.Bps 2W9 STOCKTON,CA 9=1 <br />