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FOR OFFICE USE: ea,V,pjpAPPLICATION r!
<br /> .. For.NorTTransferable,,Riivocable,Suspendable) 4
<br /> ENVIRONMEhTAI-+IEAL-T'H":PERMIT
<br /> VEPLETE IN TRIPLICATE) WATER4"11TY
<br /> Application is hereby made to the San Joaquin Local Health District fora permit.to.construct and/or..install thework herein described.This application is
<br /> i^ rhade;inCamplianc6',vi4h-SanJoa uinkC.�ounty,flrdinance.No_1 62Tand the :rules:and:regulations of.the San;Ioaquin,LQcaJ;HealttiDistrict:
<br /> . .Exact:Site;AddresS
<br /> 1 ZityfTowW I -
<br /> Name Qi.l44 Phone
<br /> A~hrner's _ {
<br /> _Address', F :.City- -
<br /> a!C.k..rse-
<br /> Gr«/1 .4=44..: License# / 9 Btlsir�esa';Rhone;
<br /> �wConliactiit's'i+lame�- �,.-, y•s y "� "';
<br /> .Contractors Address { " Emergency PhOtl ry^NAL
<br /> .r, s r tf.v.r
<br /> 15:Cer4ificate.ofWorkmar!'s-Compensation Insurance'o`n File-i. ,tl�SJLH[
<br />,- TYPE OF WORK (CHECK)-, :NEW IIV7=LL❑ DEEPEN
<br /> -,RECONQITiOhlp ,. ;QESTfiUCTION
<br /> WELtICHLIDRINAT-09f 0- :'WELL':.ABANDONMENT-©: TTHER.13-;'- aPtJ'hilP;MTALLAT1DN'�.,;":.PUMP R1=Pi44R0
<br /> REPLACEMENT-[:] -
<br /> s ': DISTANCE TO•NEAREST Septirik .: Sewer Lines Pit•Privy
<br /> • =`;:Sewart,e,Disposal,Field_: - Cesspool/Seepage Pit. Other —
<br /> s ,Fpertyal irie. .� .Pxivste>-Domestic Wen _ Public,Domestic,Wel}� --
<br /> INTENDEDrUSE _s
<br /> S
<br /> INDUSTRIAL.
<br /> ;`' AHLE'TOO:.L,- Dia.;of Well Excavation
<br /> I ...
<br /> �. . DOMESTIC/PRIVATE _ ":fl DRIL"LED_. u,Dia:_of-WeI1:Casing.
<br /> i ❑:f]OMESTIC/PUBLIC ❑. DRIVEN ' .:Gauge of Casing
<br /> iIRR1GATlONr`, n,GRAVEL PACK, De.plh of.Grout Seal
<br /> ©=CATHODIC.PROTECTION I ❑.;:ROTARY: ,. ° > °: ;..T.ype of Grout.
<br /> ❑ QISPOSAL:, ❑ 'L}THTR. :_:._ i'.Other.Information
<br /> [ CI.GEOPHYSI.CAL' a� Surface:Sea nstalled BY:. '
<br /> }...;.,PUMP INSTALLATION::.' _ Contractor- ..
<br /> .:Type of Pump ir H.P.'
<br /> PUMP REPLACEMENT-: .- Q�State V11ark,Do:rte
<br /> .; p11MP.._REPAIR::::, ....•,::..�=_v.:+K=„..
<br /> --State-Work Done L'
<br /> •DESTfUCT10N>'OEWELL_...:,: -.,_ Well-Diameter .. .,•APProximateDe lh
<br /> 4 Materlal'
<br /> Describes
<br /> �IndeProcedure: -
<br /> l-jhereby certify that i-,have prepared this application•.andithat:ihe<ln+ork--will be `one ia.accordance with Sara Joaquin Eounty<,,
<br /> 'ordinances, state laws,andTtsles-and regulations of the San,loagpinLocal Health-District..
<br /> :- - Homeownerdr-licbttedagierWssignatureceriifiesethefgltowing'''lcart
<br /> ifythatinth8.p.erformff#aceof.the.w.orkforwtaichthis•perrrlEi
<br /> o- >- is.issued,a shall not 2rnpla}many:pesst�n"�lriaLr h:Tnanner.asito become subject,to workman's mpensatiorn.taws'of:.Galifornla ,•..-
<br /> :,..
<br /> .,,Contractor's -conlractirigsigrratu eAllies,the.,fallowing:"Icertifythat,.inthe,pe#ormanceof.the.workiprwhichahis,,-.� �_r ,
<br /> permit.is issued,-I shall employ-persons'subjectato�workman:sf=mperasation laws.of Calitornia.". .,
<br /> l-.wiltsalt-tor w'Groul-Inspect-on 'or o_ g-and 0.
<br /> (Draw Plot . Ian-,on Reverse Side)
<br /> O#3ZEiPARTMENT USE ONLY
<br /> €:
<br /> '
<br /> :PHASE I
<br /> r �' DatEr ` _.
<br /> Application Accepted.By l��' '
<br /> ' .. Additional Comments_
<br /> ;. `Phase it iGrout inspection � „, -. I �hare_1 I t inabanspectivn
<br /> lnspectian,By Date Inspect-on By Date �7'
<br /> i
<br /> E' Fee IS.Que: � ANNUALi3^'r`- ❑'PER-UNIT 0 PER STT-E'' ❑ EACF-1 © January &'Rece'ivet.ayirdarFuary 31 ❑..fuly:7.TB Received By.iuly37 Y
<br /> REMIT
<br /> BILLING REMITTANCE S AMOUNT DUE :.CHECKED '
<br /> =-BASE EXPLANATION OA'T-E DATE REMITTED - AMOUNT.
<br /> '' -'•
<br /> FEE
<br /> • � 4L�' ..,C ��� _. .._ ., -
<br /> [1
<br /> ` LESS
<br /> . PRORATION
<br /> ! PLUS _
<br /> PENALTY - - -
<br /> OTHER
<br /> OTHER
<br /> 3 /.a
<br /> Received by, Date Receipt Na.
<br /> 'Permit No. Is uance Date Mailed Delivered
<br /> ...
<br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1501 E.HAZELTONYaYE..P.Q.Box 2009STOCKTON,CA 95201
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