|
:FOR OFFICE USE: ..; APPLICATION'
<br /> IFor'Ndn-Transferable,•Revocable,:Suspendable) t;'•
<br /> NVIgONMENTAL HE:ALTH
<br /> EPEF�MIT � /
<br /> fs f
<br /> i (COIIiIPCETE IN TRIPLICATE) ,WATERVUALITY
<br /> Application is hereby made to the San Joaquin.LocalHealtht3isWclJor:a,permit•toconstruct,and/Gr install the work herein described.This application is
<br /> i 'made in compliance With,San Joaquin lCourity:Ordinance.brio:.TB'S?{ i rttf0s"Snd*e&1kions of.4he Sa ' oaquin LodarHealth District.
<br /> t... ,- -Exact SiteAddress. ZitylTown .
<br /> Owner's Name. :Phone
<br /> r
<br /> Address......
<br /> C1t
<br /> F
<br /> _��c3rttlaetor's Name y ens+B#. StlaM1rses�d?hone
<br /> ,._ „Contcactors_,�ddres5 ,rr ;i ._ -' ergency.:Phorxg
<br /> {'` s'"Is.Ce"itificate`pf Wor7Ciota}Tar�Gofip'vr tlo'04A don FiW'With
<br /> t 'TY�lE OF.�WORK{ChIEGK.). . :NEW.,VifELL.❑-,t :;l]EEPEN ..,. `RECONDIT1QNt'CI °?EStRtJCT10N�.. .,.__ A
<br /> _.
<br /> :GFiL'ORiNA -1t3N Q �fVELL'A734NC1C7i�1A�l£N7 f'.. C T3�t # � .,�,l t tP f TAr'CAT1'ON ':};r'PIJIVfP REPA4
<br /> REPLACEMENT M
<br /> F � DISTANCE TO; EAREST .,.,_, peptic Tank {' r� � _: ,a5ewet des` � f ,:+PWPrivy �'-
<br /> ;., s.Sewage
<br /> 1]ispos>a:lField'P...rt�rdte.:i]oiriesti tfiCteetsl spoo..l/.See°.p:aPjueb`,.lic _Ottibr.
<br /> DomestiVMel)Poperty Line
<br /> ...,t... INTfF1OJEI7-.i)5E -5° ., .. ::TYPIECIF WELL. -
<br /> ❑
<br /> INDUSTRIAL 7::: r SABLE TOOL'``
<br /> "' ".Dia:taf.WeIFExcay.ation.. .
<br /> ...
<br /> ❑.DOiu1ESTfCJRRIVATE r <, -u»...O'DRILLED_.,_, .Dia.rof:Weil Cas➢ng_ t
<br /> OONIESTfCIPUBLIC ;;'t�iIVEN` , .., ,-,Gauge of,Casing,. -
<br /> a
<br /> `.GRAVEL PACK . u_ .:" - . ., :>�e th.of_Groutr5eal.
<br /> I. .,•:,. ,fRR1G'ATt0N P -
<br /> ❑'.CAFl-1.Ot31C PROT-ECT.ION;_...:,
<br /> [],ROTARY .r... , _ _. _:Type of Grout
<br /> ❑,DISPOSAL, ❑ .0THER '::Other Information
<br /> ":�„GEOAH'YSfCFAL : 'Surface:Seal Installed 8y
<br /> j,.. ..:'•RUMRJNSTALLA;IONC nko ;
<br /> . .. TypWof'pump H.P
<br /> u.
<br /> PL1MP=REPLXCEfflE
<br /> Ii� ;-•PUfHP::REPAIR� ,�.�,._�;- '��_'a��:�.� .�:�'lteJlilforks'�61 <:=- - .��---. � - _
<br /> l_ nDESTRUCTIQN Cf WELL. �.�—? .We`ll.iarneter Approximate-Depth
<br /> a•:. E4 ,,1:_0: � , _:� Descr�be:Matenalar#d a'cedure ,:,
<br /> l Wit.
<br /> J r I taereby'certify..thatl-.have°prepared this applidration.-and'that=iFreawork will be;ddhe'in accordance with.San Joaquin-County
<br /> a ordinances,stBte4aws,'and Tures and°regulations of the San-- -Local.Health District.
<br /> . Hon*owrter.Or4ic~d.agent'asignaturecestif€e Ahefiotivwing:-'1f ct tifythatiniheper#orr#amelDf-thewoeK-forwhichthispermit
<br /> of. is issued;=[ shad-noi•employ any persodin suctVrnahmsr.as:to be orae:Subject,to workman`s mnPensation'Iaws of-California.”
<br /> 6w: _:��.�--,_Contractor.'s:hiringorsub-contracting,signatua•certiliestheAaliowing:"I°certify that in•the�pgoarrnance.ofithework forwhichihis
<br /> {' permit is issued, 1 shall emplaypersons subjectAo�workman's ticompensation laws of California:'*.�,.
<br /> ro
<br /> y :Ia 'it Call,
<br /> ` �. . .:
<br /> specttono
<br /> r'tn.gtoutirgTand a final insp on. .. +_-=- y -
<br /> Signed.x. ..
<br /> f IDraw Plot Plan-on ReyeZSide) ,= •
<br /> ;?a::` FGt I' EPR i i<Id GfT-USE Qt�IL Y"� •+ .
<br /> S! ..PHASE I .,
<br /> : .. -Application Acsep#ed By Date.
<br /> ;: .. .. r.:;.: ,Additjonal.Comments:
<br /> 41#1aa1fl'fmaiinspection ,
<br /> n :f
<br /> jrspection By Epspection By. e_
<br /> Fee IS Due:.❑ ANNUAL ❑ PER UNIT) ` ' PER'StTE- ❑ EACH- ❑ January:l 8"Received By January 31 ❑:-July-1 71 Received By duly 31 ,r;..
<br /> {, 8 REMIT
<br /> BASE EXPf ANATION ELL"ING REMITTANCE # 3 AMOUNT,DUE rXHECKED�
<br /> k HATE DATE R MITTED e':AMOUN
<br /> FEE _4 _ ,Z
<br /> :I LESS _ r
<br /> -PRORATION - '_
<br /> PLUS - - -
<br /> PENALTY
<br /> 1, OTHER
<br /> ' OTHER
<br /> i
<br /> Received by Date Receipt No., - ' Permit No. Issuance Oate - Mailed Delivered
<br /> "* APPLICA'NT�RETURN-ALL COPIES"TO: ENVIRONMENTAL HEALTH PERMITISERVICES -1601 E.HAZELTOH AME:P:O.Box'-7009".'STOCKTON,CA 95201
<br />
|