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r � Applications Will Be Processed When Submltted Properly Completed. BeSu bsign IneAppncauun 61.7wFOR OFFICE USE: APPLICATION L AUG A 1984 <br /> (For Non-Transferable, Revocable, Suspendable) pNA�pLL <br /> YP <br /> ENVIRONMENTAL HEALTH PERMIT SAID .iURQU <br /> warEa QUALITY HEALTH DISTRICT <br />- (COMPLETE IN TRIPLICATE) <br /> Application is hereby made tothe San Joaquin Local Health Districtfora permitto construct and/or instalithe work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District, <br /> +� 044&- <br /> 09 <br /> 4n�j %€I City/Town <br /> Exact Site Address__�s��Cr <br /> Phone J `s <br /> j Owner's Name L VALKCity—S4 r7 I <br /> Address ra27 <br /> s'. p} License# 7�c�/�— Business Pho . <br /> Contractor's Name _ <br /> i Contractor's Address —RotEmergency Phone <br /> ti Yes No . <br /> k Is Certificate of Workman's Compensation Insurance <br /> File <br /> With SRECONDITION❑ DEDESTRUCTION❑ <br /> f TYPE OF WORK (CHECK): NEW DEEPEN <br /> I WELL CHLORINATION El ABANDONMENT 11OTHER C3PUMP INSTALLATION 11 PUMP REPAIR <br /> REPLACEMENT❑ <br /> Sewer Lines - Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/seepage Pit Other <br /> Sewage Disposal Field - <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> 11 INDUSTRIAL <br /> 13 CABLE TOOL Dia. of Well Excavation <br /> q DOMESTIC/PRIVATE C3 DRILLED Dia. of Well Casing <br /> 13DRIVEN Gauge of Casing <br /> 13 DOMESTIC/PUBLIC <br /> 11 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> { <br /> 11 CATHODIC PROTECTION <br /> 13 ROTARY Type of Grout <br /> t <br /> ❑ OTHER Other information <br /> ❑ DISPOSAL R-� <br /> ❑ GEOPHYSICAL Surface Seal installed By: <br /> PUMP INSTALLATION: Contractor i <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: <br /> El State Work Done .` <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION OF WELL: <br /> Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prep are this <br /> saplicatioons of thand e San t the won rk alll be done <br /> in t accordance with San Joaquin County <br /> ordinances, state laws, and d <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> z-is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-co <br /> signature certifies the following:"I certify that in the performance of the work forwhich this , <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." rl <br /> I wi 11 for i Ins ction prior to grouting and a final inspects n p ��' <br /> Title: <br /> Dale: <br /> Signed X <br /> (Draw Plot Plan on Reverse Side) <br /> OR DrIPARTMENT USE ONLY <br /> PHASE I � /p Date <br /> 5 <br /> Application Accepted By <br /> I Additional Comments: Phase III Final Inspection <br /> Phase It Grout Inspection Date <br /> Inspection By Date Inspection 8y <br /> PER UNIT 191PER SITE ❑ EACH C1 January 1 &Received By January 31 ❑ July 1 &ReceivedREMIT 31 <br /> Fee is Due: El ANNUALLY ❑ <br /> BILLING REMITTANCE $ MOUNT RUE CHECKED <br /> BASE - EXPLANATION DATE DATE REMITTED AMOUNT f <br /> f <br /> FEE <br /> LESS <br /> PRORATION L <br /> PLUS (J <br /> i PENALTY <br /> OTHER <br /> ik OTHER <br /> [ Issuance Date Mailed - Delivered <br /> ate Receipt No. e <br /> Received by .it No. <br /> 1BDY E:HAZELTDN AVE.,P.O.Box 2009 STOCKTON,CA 952( <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES T - <br />