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Apprlcanons will ere Processea when 5uontlttea Pri�psrly Gornptetea. tie Sure To Sign The Application, <br /> ,- FOR OFFICE USE: APPLICATION <br /> 11 (For Non-Transferable, Revocable, Suspendabie) UNIP,iu ELl <br /> " , �° - ENVIRONMENTAL HEALTH PERMIT °s ` <br /> ,-, <br /> F <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This appf'scati,on is <br /> made in compliance with San Joa n County Ordinance No.�1862 and the rules and regulations of the San Joaquin Local Health District <br /> Exact Site Address A—[ <br /> _ li`'l` � � City/Town <br /> Owner's Name �PI-6_le_ '?_ 7_ Pt Phone I` r <br /> }f AAA <br /> Address City r <br /> F Contractor's Name � License# usiness Phone <br /> Contractor's Address .--. 71nq Emergency Phone <br /> lIs Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ►/ No <br /> TYPE OF WORK (CHECK): NEW WELL/ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIOf� PUMP REPAIR❑ <br /> REPt_ACEMENT❑ L <br /> i DISTANCE; TO NEAREST: Septic Tank V Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line_. .(.� Pr,vat Dor�sti�c,'Vy�lh�_-y. public Domestic Weil <br /> INTENDED USE TYPE OF WIL i `� <br /> ❑ DUSTRIAE - -- -•--G�-CABL€ L- -�- - E3+a>of-Wefl-E�ccavation - t ( 7 ,_._ _. <br /> Lr DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing1 <br /> k ❑ DOMESTIC/PUBLIC S f ❑ DRIVEN Gauge of Casing <br /> El IRRIGATION i ❑ AVEL PACK Depth of Grout Seal � • <br /> ❑ CATHODIC PROTECTION ROTARY Type of GroutG <br /> ❑ DISPOSAL OTHER Other Information ^Y <br /> ❑ GEOPHYSICAL Surface Seal Installed By: �ttr <br /> PUMP INSTALLATION: I Contractor <br /> I Ype of Pump isy t?211 �-� { i HIP. <br /> PUMP REPLACEMENT: i i State Work Done t <br /> PUMP REPAIR: ; /❑ State Work Done <br /> DESTRUCTION OF WELL; ell Diameter Appro i to-Depth <br /> t E ! ascribe Material and Procedure 4 <br /> I hereby certify that I ha4 F <br /> prepared this application and that She work will be done in accordance with San Joaquin County <br /> ordinances, state laws, anti rules and regulations of the San Joaquin Local Health District. <br /> J <br /> Homeowner or licensedagent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, I shall not emplay any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracling signature certifies the following:"I certify that in the performance of the work for which this <br /> i permit is issued, I shall �niploy persons subject to workman's compensation laws of California." <br /> I}yiH��I for a Grout In�pl on pr' to outing and a final inspection. <br /> Signed X ..� '` �J Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> i t <br /> j FOR DEPARTMENT USE ONLY <br /> PHASE I f E <br /> Application Accepted By `-� -- Date <br /> -0 -Additional Comments: _ <br /> Py <br /> jGroul-fnsp c4;lo � � V P III Final Inspection <br /> In'sp"ion By - Y' s ec> s �y Date -` �1:l <br /> 0 r ► _ <br /> I Fee Is Due: ❑ ANNUA Y PER NIT ❑ PER SITE ❑ E CH ❑ is ua 1 &R ei d y nuar ❑ July 1 &Received By July 30 <br /> a -__. t <br /> I i BILLING REMTrA CE $ REMIT i <br /> "• 'iE EXPLANATION AMOUNT DUE CHECKED <br /> PATE DATE; REMITTED <br /> � QQ AMOUNT <br /> FEE E V� <br /> ' LESS l <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> FOTHER <br /> F <br /> — <br /> i <br /> OTHER � ,...._-._...__..�._.�_..�....._�....._...._...... <br /> ateLt <br /> _ <br /> Received by Dale Receipt No. Permil No I sua ce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />