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�.---' - _ ,_ ArrL_1%.AI IViV
<br /> FOR OFFICE LISE.
<br /> For:Non-Transferable,•-Revocable,Suspendable)
<br /> ENVIRONMENTAL HEFLTH'PERMIT
<br /> (COMPLETE-IN'TRiPLICAT>=) ''° WATER QuAt1TY
<br /> Application.is.hereby,,made to the San Joaquin Local Health-District}oracp.er-rnit-to.construct and/or install the work herein described.This applicatior
<br /> made,in.compliancewith an;Joaquin County,Ordinance ,;,4.86 ,aid tkle rales and-ragufations of;the.Sa .loaq in Local Health District.
<br /> Exact Site Address D C[tylTAwn, � �1 � _
<br /> :. r
<br /> ;. .Owner's Name A19 X& Phone ..s_
<br />:i Address - -- -- City.
<br /> Contractors Name. L7cense:fi s f/ _ Business Phone
<br /> r ._....Contractors Address: 3 � _x�c:� a. , moi _ Emergency Phone '
<br /> Is Certificate af,.Workrrlan s Compensation.insurance on File;With SJLHD?; - Yes
<br /> TYPE OF WORK (CHECK) ,NEW..WECL DEEPEN ❑ :AECOfdEJI710fV❑ DESTRLiCTION�
<br /> WELD;;GHLORINA,AT ❑_. . _W£Ll"AE,ANDONMENT�,dE�, OTi'1 7 1i :'PINI
<br /> IP;7TNSTAULAT1O1V ..""PUMP°REPAIR❑ (Q
<br /> ~
<br /> :REPLACEMENT-0 V"
<br /> 'DISTAIICETO NEAREST .Septic Tank.��f�: :^� Sewer•Lines _ �'F f?it Privy
<br /> -.-. -
<br /> ,�wage Disposal Field^ r� Cesspooll5eepage Pit Other ?
<br /> t-ProReriy,Line °Pnvate;Oornestic lllfell„ :'Public Domestic•Well
<br /> INTENDED-USE
<br /> '.TYPE,-0VWELL !1
<br /> ❑ INDUSTRIAL � Q-4cASLETOOL- .Dja_�-of-Welt Excavation
<br /> -DOMESTIG/PRIVATE U"DR,LLE.D pia. Well,-Casing_
<br /> ri
<br /> - r
<br /> f70MES7ECIPUBLIC UAIVEN. ,::gauge of Casing.. d
<br /> .11-IRRIGATION g;GAAVEL,PACK. --Depth of Grout Seal J
<br /> -© CATHODICPROTECTION ROTARY .,- _Type_of Grout. _ - �giv i —.
<br /> -- -
<br /> ❑ DISPOSAL ❑ .OTHER r .OZher Information. 1+
<br /> . 0_GEOPHYSICAL ', > . -• :, Surface.Seal-Installed'By: jQ OJAI
<br /> PUMA?.INSTALLATION: Contractor
<br /> Type of Pump H.P. .
<br /> -PUMP REPLACEMENT."'' .0 State Work Done,
<br /> State Work -
<br />-, DESTRAJCT;ION OF WFLL:; pWell Diameter -_ - Approximate Depth, y -
<br /> _--- ;Describe Material and.P-rocedure...,
<br /> J,4o by certify that 1 have:prepared this applscat'On-.and thatAhe*work,will be done..in,accordance-.with.-San:Jnlaquin:County
<br /> ordinances;state Uws,-and.Tules and regulations of the San Joaquin Local Health District.
<br />'- figmeowner-orllcerSsedagent's signature certifies the ollowing,Iicertifythetintheperformance of-thework fdrwhich-thispermit
<br /> as issued ;Ishall,not.emptoy..any person in such;manger.as,to-become subject to workman's compensation taws of.California." '
<br /> _ Co>7lracts�rs.,.iltring.9. 9 ponlracting signature:certittes th Jo lowing:,"li certify that in the pg4brmance of the work for whidhthis
<br /> permit-is issued', I shall emplay-.persons subject.to workman's compensation laws of California."" _
<br /> will:calt,tora' rn nsP . it prior to-grouting and a final inspection. ._ -.
<br />` • .. Signed x- Title: h/ L :Date:
<br /> - - -
<br /> (Draw Plot Plan an Reverse
<br /> F. e)'
<br /> x otF�3R UIEP. TMl ta. .USE:ONLY
<br /> ,PHASE 1
<br /> Application Accepted Syr _ Date.
<br /> I Additional Comments: -
<br /> - f?base i Grout Inspection : Phase ti!final Inspection '
<br /> r ,.. _
<br /> inspection By Date_1 Z61` Inspection By ° Date /d /
<br /> r
<br /> Fee IS 104.1e:.O-ANNUAI3A'4'1;' ❑-PER.,UNIT ❑ EACH ❑,January 1.',& eceived By January 31 - 0 Juty 1 8 ReC�eived.By July 31
<br />} E
<br /> BILLING RMITTANCE j REMIT
<br /> + BASE - EXPLANATION• AMOUNT DUE '1CHEClCED
<br /> DATE DATE AEMITTED AMOUNT
<br /># FEE - -
<br />,i
<br /> .--PRORATION--
<br /> PENALTY--PRORATIONPENALTY
<br /> • OTHER
<br /> OTHER
<br /> 11'
<br /> -Received by Date Receipt No. - Permit No.- ,. Wuarlce Date -- Mailed `w Delivered
<br /> F: - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E_HAZELTON AVE_P.O.Bo=2009 STOCKTON.CA 95201
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