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•l•r•••••••••v..o ....� vc - -----ay.. ....c.. v.av..... r. p—, —...F.�cacu _x; aurc a�ryi1 IIi_wAF7�7ft�a��Un. _ <br /> ' FOR OFFICE USE: APPLICATION <br /> - F (Far Non-Transferable;Revocable;'Suspendable) 7 <br /> '::'ENV.IRONMENTAL,HEAL-TH-PERMIT':,,:, <br /> (COMPLETE IN TRIPLICATE) " ' -`WATER1QUAL1TY `- <' r <br /> Application is hereby made to the San-Joaquin Local Health District fora permit to construct andforinstaIll the work hei'eln.described.This application is <br /> made in compliance with an Joaq Gotflity'Ordinance No,1862 and the rules and regulations of..the San Jo uiri 'ol i;Health District. <br /> Exact Site Address �L ��—� � �i^ Ci!y/Town _ <br /> Owner's NamL1�Zl C .iGi ��4 � � Phone R .L / <br /> Address. _T l City ___ <br /> Contractor's Name License# Business Phone_'- . <br /> k Contractor's Address ' Emergency Phone \ <br /> fF Is'Certificate of Wcrkman's,Compensation Insurance on File With SJLHD? --Yes <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ ..-RECONDITION 0 'DESTRUCTIQNQ C <br /> LL CH LORINAT11ON ❑ WELL--.A-BANDONMENT,4. �-,RUM_0 INStA't_LAT-ION© PUINP;fIEPAiR❑ C <br /> REPLACEMENT❑ # ,_. . <br /> i DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Di-sposal Field.'- > = T Cesspool/Seepage Pit Othei_ 1 <br /> Property Line. Private Domesr ip.,Well •Pubfic-Domestic Well V1 <br /> INTENDED USE ., ..,. _TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE'TOOt,;Ea, Dia of-Welf:Excavation <br /> DOMESTIC/PRIVATE .. ; ❑ DRILLED t. s Dia. of•Well-.Casin'g <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION "" ❑ GRAVEL PACK .'�._- Depth of Grout Seal _ <br /> F ❑ CATHODIC PROTECTION ❑ .ROT-ARY Type lof Grout y <br /> ❑ DISPOSAL ,- ❑ OTHER Other Information __- <br /> ❑ GEOPHYSICAL ;;� ,. ) Surface Seal Installed <br /> ' PUMP INS-TALLATION: ., .,, j.Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: i❑ State Work Done <br /> s PUMP REPAIR:;:.._ 3❑ State Work Done .,._..... <br /> ` DESTRUCTION OF WELL: ..... Well Diameterproxllnate Depth ._ <br /> I <br /> Describe,.Mater 1 and Procedure +. _.s _C11-14 cr 11-4 <br /> I hereby certify that1 have prep4d this application-,and that the work-.will be done in accordlin(m-with Sall Joaquin County. <br /> ordinances, state laws, and rules-and regulations of the San Joaquin Local Health District. f <br /> Home owner or..licensed agent's signature certifies the loilowing:."I certify-that in theperformancegf the work for which this permit- <br /> } is issued -shall not•em I an <br /> i -1 p oy y person,in such mapper as ta.become subject to workrttan's,compenBation lavvs:o#.California:" . <br /> ` Contractor's hiring orsub=contracting•signatures4rUftes;thefollowing:1-certify in the performince of thewtirk�*# rwhich this <br /> permit is issued, I shall employ persons subject-to•workrilan's compensation laws;of California." , <br /> 1 <br /> I wiN II for a Grout l ection prior to grouting and a final inspection. t.•. - -. <br /> �,� I <br /> Signed Xa.�+7� Title: Dais: <br /> 11 (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> I PHASEd <br /> - Application Accepted By :Date' <br /> Additional.Comments: <br /> Phase It Grout Inspection Phase III F at Ihepeofion . <br /> lInspection-By Date Inspection-8y.' C ' pate <br /> Fee ls'Due: ❑,.ANNUAtL-y- - [3-PER UNIT ❑ PER SITE 19-fA044 January 1 &Received By January;31 - [] July 1 &Received By July 31 <br /> -BtLLING REMITTANCE 1�% REMIT <br /> EXPLANATION-'-:- -_ DATE DATEF REMITTED �`AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE /13 <br /> LESS `7 <br /> PRORATION 18 ^]. - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER I <br /> Z9_ Sags-� __ <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAIELTON AVE.,P.O.Box 2009 STO <br /> a <br />