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— F6 6FF10E l7SE.! F[F't'LIC►H1 1V1�1 i r`�l vt.-, <br /> -(For.Non-Transterable, Revocable,Suspendable) ° <br /> n <br /> I ENVIRONMENTAL HEALTH'PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE):'''`'' j <br /> Application is hereby made to the San Joaquin Local Health Disirict-fora permit to construct and/or install.thework herein described.This applicavio <br /> made in compliance with//San,Joaquin County Ordina ceNo 1882 and the,;ruies:-and regulations of1hi San'Joaquin,LocaI Health District. <br /> Exact Site Address L . <br /> i - �Owner's AlamePhone.. <br /> Address -- - ..". .. City <br /> Contractor s;Name . ce <br /> Linse If C?.tel _Business Phone y � Z !n <br /> r� jr ff <br /> Contractors_-Ad dress.._s.a ; ' .S �icFL.i S1 Em+argeriay Phone <br /> Is Ceitlflcate of Workmen s Compensation,lnsurance on File Wlth S,fLHfl_ <br /> "TYPE OF';W0 K;(CHECK).,;; N>wW-11vELl C?EPP,EN 3 . . RECONDITION❑ DESTRUCTiONL�.. � <br /> W1=L'`i:: CHLORINATiON:=❑ W.{1rL"TAB_ANDONMENTINSTAIi '..'..PUMP REPAIR© --.` <br /> REPLACEMENT-0 <br /> #; !?1STANCE TO NEAREST: septicTank,-rte Sewer Lines.1. Cj <br /> +Sewa a 01 asal Feld':_ I� Cesspool/ Pit t7==, Other <br /> .Property une„ G�Private Domestic-WWell _ .... Public Dornestic::Well- :: .. . <br /> INTENDED.USE YPE.0 F.WELL b <br /> i. :INDUSTRIAL -,'- 'O CABLE TOOL- Dia.�of'WellExcavation <br /> DO.MESI IC/PRIVATE; Q:DRILLED _Dia. of Well Gasing <br /> 13,q)OMESTIC/PUBLIC -0-,DRIVEN. :gauge of Casing <br /> .F-]..IRRIGATION ''"t'"GRAVEL:PACK :;. "-Depth:of-GroutSeal, <br /> }' y <br /> ❑ CATHODtB PF3DTEnCTION _,.: _ Fl -ROTARYType of Grout Y <br /> .❑ DISPOSAL., - a ❑ OTHER :;Other Information <br /> ` :-O.GEOPHYSICAL ,. Surface-Seal Installed By., <br /> s :PUMP IN, Contractor m- ” <br /> �'. Type of Pump HIP,. <br /> 'PUMP REPLACEfi71ENT: .. t °.L7 state Work Rorie. -' <br /> 1- PUMP REPAIR - St$le.Ytr-ork Done <br /> DESTRUCTION QF-WF1L' -Well-Diameter._ ;' Y Approximate Depth -- <br /> Desc jbigMaterial androcedure <br /> -hereby cern that 1 have,-prepared,tfm3a licafion and that-4he-wor-Ic will 6e don ;Accordance with San-Joaquin Count <br /> ;ordinances,stato.taws;-and:�s•and:regulations:of the San_Joaquin Local Health:District.i,%, -= <br /> 'ssi natof:the-workfor which'this ermitHgmeowterorlr' g .niu <br /> _ is.;issued, 1 shall%not emj►py any•person.in such manner•as-stnteom,"ubject-to:<wofkrrian's accympensatic n laws!OV0alif6r6ia_" ' <br /> o" Contractors Kirin arsubontractiPg sigrsature certifies,the:following-"1 certityhat•>ih tfli pe#ormance of the work forwhichFthis-- <br /> permit is issued,!shall employ-personssubject to workman's compensation laws of.California". <br /> ,;-r>1 will calt.for a'Gro t1risp on p -grouting and a final inspection. .. <br /> _ 1 <br /> Signed 7(! Title:- - - ::Dais: <br /> „(Draw Plot Plan on Reverse S e) <br /> ^. . - <br /> F aFi <br /> !,.-_FODEPAR MENT,.USE--ONLY r� <br /> 'PHASE 1 <br /> Application Accepted By Date. <br /> Agditional Comments: <br /> .. <br /> Inspection ay, '�" ut s Date n .� Inspection By `t Phase-111 Fi i inspection ate€ _ <br /> r I2U GJ`�- Q - <br /> g Fee IS;I7ue..❑,ANNUAti�F fT ©'"PER UNIT ,�G PER-SrTE ❑.EACH. 11 January 7 &'Received By January 31 © July t d ReceHed By Juty 37 <br /> i - REMIT <br /> 'BASE EXPLANATION- BILLING REMITTANCE $ AMOUNT DUE =VHECKED <br /> n.. <br /> -4_ ? <br /> DATE ,; DATE REMITTED AMOUNT <br /> L.,. 7. <br /> FEE.. d <br /> LESS +z <br /> ..PRORATION_ <br /> "PLUS. .. ., <br /> } _ PENALTY ' <br /> 1s OTHER <br /> OTHER <br /> a Received by i Date f Receipt No. --r Permit No. Iuanbe Date,4, 1 Mailed Delivered <br /> APPLICANT--RETURN ALL COPICS TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HA2EL70N AVE-P.O.Son 2002 STOCK70N,CA 45 <br />