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FOR aFFlc� USE: APPLICATION
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<br /> ••e,(For_Non-`iransferabte; Revocable, Suspendabie}
<br /> / y .
<br /> ENVIRONMENTAL HEALTHTERMIT
<br />' (COMPLETE IN TRIPLICATE) "..:WATER QUALITY
<br /> .Application is hereby made to..theSan-Joagtiin.Local Health Distnct,fora.permit:tb'.cbnstructand;.orinstalttbework herein.descr.ibed Thts:appllcationis
<br /> made an:corispliarice With:Sari.JoaQuin-Courtty.Or nance:d� 1.86�end,ttt�r>u��s end regataUstris n3 the:.San: oaquin.L cal;Health•District ` .
<br /> . .Exact-Site Address,
<br /> Owner's_Name_
<br /> 0-
<br /> .,-,Address ;:City
<br /> Contractors:idarne L r&nse`# Re
<br /> GnntractQr s,hddress ;" fyrgenc�rXPho.�
<br /> r
<br /> .+:Is'Gertiticafe:�t�c�Fkm$n's:Corripensatldrt 1r1��a�rce�orrFll�iNitFr�f=1E}J?"�=r�-Yas �
<br /> TYPE':6F'WORK(CHECK):1 . NEW'WS ELT3,s,S� IJEEPEN Q , -RECONDITIIf DESTRIICTION�` P
<br /> bit L1-Cl{f Ol�lluAfFlt7f�1'� r_WELL;iA'BAT�tt�VMENT43 "OTacl l�y '1�L7(�7iP- STAI LATIION�, : PUMP;"REPAIR©
<br /> REPLACEMENT'S
<br /> l?lSTANCE TO NEAREST:s:tea Septic Tank Ssrver.:L�sbs a x PitPricy;
<br /> 4 ewage flisposal ,jpld Cesspod.11Seepage;Pit : Other .
<br /> Public<Domestic llyall
<br /> 'P,roperty.-Line Ate'-�tilrate:Domestic Well
<br /> :INTENDED;U5E- -WELL
<br /> ❑ INDUSTRIAL.. `;':�' D%CABLE.:70OL-_ .:.Dia.~of Well:Excavation
<br /> ©...I�OMEST:IC%P#ilVATE 0=DfiILLED ...__.. ,,:Dia.Df.;Well;Casing
<br /> 0;'f�OIIAESTIC/PUBLIC L ::DRIV-EN Ctaujec7t:'.Casing
<br /> :DiRRiGATf6]N: . . sLa:GF3AV' L,PACIC_'', ;~ Jpthfrot5eal �'
<br /> ❑ '.CA.THODIC,P.ROTECTION ❑:f30TARY,:3�w_� .::. : ., T3rpe.ofia3[rtut.,';«� ;, . '
<br /> _,. .0:.D.1SPOSAL..._-_. ,. ❑:Q HFR i. __-.__ _ 4.. :Other_lnformationry
<br /> urface.5ea tall _
<br /> I lns ed By i
<br /> 0.GEOPHYSICAL
<br /> ._ ,
<br /> .: ;PL1tNP,tfVSALLATJIQN_
<br /> .. t . ��ypoPump P.0 t ,
<br /> PU1tAP.3tEP.LACEME
<br /> XT:
<br /> : r �State,_Work Do.n
<br /> PUMP_-:REPAIR,µem State�lVnckaae ' =
<br /> CIEST,RtiCTialV OF YELL. _.,.�-» r,'<•, ell_Diameterf Appravrnate.Depth
<br /> I
<br /> Describe Material and PtQcedure
<br />.. 1 hereby,Certify that i;have•prepared-..this,;applicat orr-and thatathezWnrk-wilt-be-done irt>accordance with San.loaquln County..
<br /> ordinances,_statelaws aand,ruies and regulations of the San-doagi in Local Heattl'1 District. r """' ""
<br /> l_ =,�e.�: W,a_-Home:ownerbrlicerirsedag.eht's.$ignatureee.ctifies the fnilowiitgIaetifythatyatfieperior:mar~cent.iheworkfoYwf►ichtfiisperrnit
<br /> _- „is:issued Lshall,not empioy any:persalt:in.•such~marmer'as to:be-corh6 subject.t1Ovorkman's:1campensation laws ofCalifornia.-
<br /> 1 =� oniractors:hiring.ot•=sub-contracting:Signa.lure,certifiesAbe:loRowing I:certifyLAhathin•the,pe>dorJnaneeof:the_work-forwhi.ch.this.
<br /> permit.is.issued,-l-shall--d-mploy-parsons subjectto workman's co mpensation'daws of Cal ifamia".> --
<br /> I:kri}i;callfor"a"Gr 1nApe ��an'pTiordo-groutlrtg.and.a finel inspe is _
<br /> signed
<br /> '(Draw.Plat Plan on Reverse Side)
<br /> - ;,,F.OR-DEPAftTAAE.NT USE DNLY .,. _ ...
<br /> P.liASE 1 ..
<br /> t
<br /> ,_-_Application Accepted By Date
<br /> Addiiional Comments:
<br /> E ;. . . .. :, ... 1 i ase'!!1 Final inspection -
<br /> I ,..:Phase.l3-_Grout tnspeCtion: � �'
<br /> _; ,_lnspectian By
<br /> Vie_ Inspection-By to
<br /> ^'Fee.IS Due:.0 ANNUALC*F -" 0 PER UNIT' fl PER! E-" 0 EACH ❑ January 1 &''Received 8y January 31 © July 1 S'Ra�ived.By July 31
<br /> .. .___._: �ANCE , ••: A REMIT
<br /> -"-,t£XPLANATION ; BILLING REMITf MOLrNTDUE CBASE DATE' DAREMITTED AMOUNT -
<br /> L .�.
<br /> I ^FEE
<br /> w..LESS
<br /> PRORATION
<br /> PLUS
<br /> PENALTY
<br /> OTHER
<br /> OTHER
<br /> I Received by / Date Receipt No - Permit No. Issuance Date Maiied Delivered
<br /> ! - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES _ 1601 E.HAZELTON AVE..P_O.Box 200T"'STOCKTON,CA 95201
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