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Willtiet'rocessvu wncnamu.+..... ..r. ..� r. <br /> APPLICATION ' <br /> FOR,OFFIGE USE: , <br /> 5r r (For Non-Transferable;Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH'PERMIT, <br /> (COMPLETE IN TRIPLICATE) t �JWp k t ;4A"L1TY <br /> Application is hereby made to the San"3baquin Local Health D.istrictfor.apermittoconstructand/orinstallthework herein described.This application is <br /> made in compliance with San Joaquin County-Ord in ance:,Nar:?11"862 and the rules and regulations of-the San Joaquin Local Health District. <br /> Exact Site Addressor" 11490 = is TY �� City/Town <br /> �1-4- <br /> Owner's Name I Irl Z Pttarae <br /> Address -il 14 SID W <br /> c71�C�1 . p1d Cityr <br /> �' 4 • ��I ' cense# � ( $usiness Phone <br /> ..,,Contractor's Name �'"'�'`y <br /> Contractor's Address 6 <br /> e Emergency Phone <br /> Is Certificate of WdrkrnaWs-Compensation insurance on File With.SJLHD? Yes .. No m=:- <br /> TYPE'.OF WORK (CHECK): . -NEW WELL O' DEEPEN ❑ RECONDITION 1:3 DESTRUCTION❑ <br /> WELL CHLORINATION El '._."WELL ABANDONMENT'❑ -OTHER ❑ PUMP`"iNSTALLATION ❑ PUMP-REPAIR❑ <br /> ::REPLACEMENT❑ ! <br /> ::'DiSTANCE TO NEAREST: -Septic Tank fi Sewer L+nes Pit Privy <br />. . ;: ' -Sewage Dispcfsal Field <br /> Cesspool/Seepage Pit Other <br /> ' Public Domestic Well <br /> Property'Line R�ivatl3i.Domestic'Welt , <br /> INTENDED USE <br /> '_. TYPE OF WELL <br /> 13 CABLE TOOL Dia..of.Well Excavation. - t <br /> '❑. INDUSTRIAL- - �Its n , �!! ✓6 <br /> DOMESTIC/PRIVATE DRILLED .of Well Casing �9 <br /> ❑.DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ILoOlUI �! <br /> 1:1 IRRIGATION ®'GRAVEL PACK Depth of Grout Seal <br /> IT CATHODIC PROTECTION G21ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHEROther Information <br /> ElGEOPHYSICAL f -:' Surface Seal Installed By:. <br /> PUMP.INSTALLATION: - Contractor <br /> Type.of Pump H.P. <br /> ❑ State Work Doney Y <br /> PUMP REPLACEMENT_„��-. _ � ... <br /> PUMP REPAIR: ”. 0 State Work Done <br /> Approximate.Depth <br /> DESTRUCTION OF WELL. Welt Diameter <br /> Describe Mate • and Proc�,du z <br /> I LM �.I , . <br /> I hereby Certify that I have prepared this application and that the work will be done in accordance with San_Joaquin-County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health-District. -� <br /> "f that in the erformanoe.of'.the work for which this permit <br />! Home owner or licensed agent's signature certifies the-fottovring:"I certify P <br /> is issued, I shall not employ any person in-such manner as to-become subject to workman's compensation laws aLCalifornia." <br /> Contractor's hiring or sub-contracting signature certifies the following:".l certify that in the performance of the work for which this <br /> y <br /> ,'persons.subject to workman's compensation laws of California." <br /> permit is issued, f'shalf::empfa - <br /> l will call for a-Gribut Inspection priorto-grouting and a final inspection. r� I <br /> Signed X <br /> Title: Date: ! •_ Z4 'I <br /> 1 rA(Draw Piot Plan on Reverse Side) <br /> -PHASE I <br /> FOR DEPAR MEENT USE ONLY <br /> = Date <br /> Application Accepted By <br /> .Additional Comments: <br /> .rPhase:liGrout Inspection Phase Ili Final Inspection <br /> _.,_.-Inspection By <br /> I Date Inspection By Date <br /> Fee-Is-Due: ❑ ANNUALLY ❑ PER UNI -PER SITE H !/ C3 January 1 &Received By January 31 July 1 &ReceivedREMIT <br /> uIy 3 <br /> BILLING REMITTANCE $ AMOUNT-DUE CHECKED <br /> BASE <br /> EXPLANATION ""-OAT DATE REMITTED = - AMOUNT <br /> FEE / - <br /> LESS <br /> PRORATION " <br /> i PLUS . <br /> PENALTY <br /> OTHER <br /> j OTHER - <br /> Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> i Received by <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STgCKTON,CA 95201 <br /> r APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />