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;.APPlkcatlons rr111 4Crrvccasma �..cnau.+uuucur.vF.c- .� ........p.•..�... .... ....... .� .�.. ... rr•• . <br /> FOR'OFFICE USE: APPLICATION w. <br /> ForNon-Transferablle Rerocable,.Si]'s endabfe ' <br /> u _ ENVIRONMENTAL`HEALTR PERMIT <br /> yFri - <br /> (COMPLETE IN TRIPLICATE) 11ifVER'I;t1dA'Lil1f ` <br /> Application is hereby mail'etothe San JoaquinLocal Health-Oistrictfora permitto construct and/or install the work herein described,This application is <br /> i made in compliance With San Joaquin-County,0rd•rnance No.-.i 862 and the rules-and regulations of the San Joaquin t_doal Health District, <br /> I Exact 5ite.Address yl+iMf�r�t La`K rt1~ kcl - r-i V4 1'YZI• City/Town 1-- C_y <br /> j C 04- - rt " �. e . Ss 11 <br /> Owner's Name (',hi�Y �i��r1 QCra Lon � _ _ _;Phone �r7-_•23�y <br />{ Address _ jl I q .A(tar"', -JRA . _ City Trcl"c <br /> i Contractor's Name ` -� License#, �Q�isl,3 :Business Phone,— <br /> Contractor's <br /> Ii Contractor's AddrQss P ` "Emergency Phone - <br /> - is Certificate of W61­krnanis.,Compensation Insurance on File With-SJLHD? Yes ._._. No, <br /> TYPE OF WORK (CHECK):­` NEW WELLS DEEPEN,❑' RECONDITION© '.: '.DESTRUCTION❑. <br /> -WELL CHLORINATION 1:1WELL" A$ANDONMI=NT OTHER ❑ ' P17h71P IITALLATIOIV ❑' " PUMP 11EPAIR� <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic.Tank jQU ! IS <br /> Sewer Lines Pit Privy _..— .. - <br /> Sewage.Disposal Field Cesspool/Seepage Pit OthHr" <br /> "`..:_`,>P.roperty'LibePrivate Domestic Well Public Domestic Well <br /> INTENDED:USE TYPE OF WELL <br /> ❑ <br /> INDUSTRIAL ❑::CABLE TOOL Dia. of Well Excavation <br /> M'DOMESTIC/PRIVATE DRILLED: Dia. of Well Casing <br /> •❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing c�QLt.) <br /> •-❑ IRRIGATION -- M—GRAVEL-PACK~ ,Depth of Grout Sea! <br /> =.••11,CAT4-1ODIC-PROTECTION- M'ROTARY..- Tyype of Grout P1 Yl= <br /> rI ❑ DISPOSAL ❑ OTHER Other Information C 11�_ft_ C <br /> ❑-GEOPHYSICAL Surface Seal Installed By: 4 <br /> PUMP INSTALLATION: Contractor <br /> t Type of Pump H.P. -- <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State-Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material.andwP,;racedure <br /> tI hereby'8ertify'•that I have preparLsd-lhis application and.that the work will be done:in>accordance.with `.yin Joaquin County �[ <br /> ordinances, state laves, and rules and regulations of the San Joaquin Local Health:District. a <br /> Home owner or licensed agent's signature certifies the following:"I certify that in-the-performance of thevuotk for which thix permit <br /> is issued. 1 shall not employ any person-in such manner as to become subject:Tto workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the fottowing:"I certify that in the performance of the work for Which this <br /> r permit is issued, I shall employ persons subject to workman's compensation:laws of California." yu. <br /> f1 will call-for,&JOrout Inspection prior to grouting and a final inspection. <br /> j. Signed X J Title: = �� Date: r7 `� - '79 <br /> k (Draw Plot Plan on Reverse Side) <br /> { FO DEPART ENT USE ONLY <br /> PHASE n <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout Inspection P se Ili Final Inapegtiort ' <br /> ff <br /> f I v.Inspection�By - Date nspection By �' Date <br /> f Feels Due:LD ANNUALLY'` ❑ PER UNIT PER SI ❑ A N V 0 J 1&'Received By January 31 a July i 9 Received By JWy 31 <br /> REMIT <br /> BASE ExkA:NATION BILLING REMITTANCE. $ AMOUNT bur -CHECKED <br /> ATE DATEREMITTED AMOUNT <br /> r <br /> FEE �5 <br /> LESS <br /> PRORATION _ S ( <br /> PLUS <br /> PENALTY ., <br /> OTHER <br /> OTHER <br /> 79� Lyy <br /> ? Received by -Date Receipt No. Permil No. Issuance"Date 'Mailed - Delivered <br /> APPLICANT—RETURN ALL cOPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AV P.O.Box 2009 tMr+^ S-TvOCK-T�ON,CA 452012 <br /> . <br /> - I t e�Ni►-Ax -? <br />