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FOR OFFICE USE: APPLICATION P "� <br /> '••":.(For-Non-Transferable,-ftevocable,5uspendable) <br /> :,--ENVIRONMENTAL HLALTH'PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER•9UALITY <br /> Application is,hereby made to the San Joaquin Local Health District fora permit.to construct and>orfnstalithe work herein described.This application <br /> .:_,made,in compliance.,with_,San;Joagmin;County.;prdinance No_;166?..and'$he,Tr., fps'Ar d;Tegulations of-1he.San,Joaquin LQcai Health�Distr k <br /> Exact Site Address. ity/Town. X r l 'P 7Ili <br />,.: Qwners Name C j <br /> _ Phong <br /> Address.. City <br /> _,-Contractor's Name_; .. d" License Business Phone <br /> Contractor s Address - mergency_Phone <br /> o <br /> m _ _ _ Insuracice'on File!V+llthS}LFiD?-. 'fes <br /> Is CertiTicale of Workman s Compensation <br /> TYPE OF WDRK (CHECK) .,.NEW WELA DEEPEtd � ':RECONDITION0 DESTRUCTIONI� <br /> WfrCl`CFiLOR1i�1,F,tfON y; WEL1 ABANDONMENT 0114ERr[ PUh7IP'fNSTAtt;4T1C?tq:� .- `wUH1P REPAiR0 :' { <br /> 'REPLACEMENTS f .rr. V <br /> •:DISTANCE TO.:'NEAf E-ST >;:Septic Tank a t3 :T Sewer nes SC) (- Pit Privy„ — . <br /> .^�ewageOisposaf Field ^'. o Cesspool/Seepage Pit :.Other_ <br /> Prope_rt Line_/^--�.kL,,Private;DoMestic Wen L�o Public Domestic Well -- <br /> INTENDED-.11SE . a.. . TYPF-.OF.WELL i r <br /> ❑ INDUSTRIAL yE :. -"©%GABLE TOOL- �Dia_--of Well Excavation <br /> DOMESTIC/PRIVATE [J-DRILLED <br /> Dia. of Well Casing, <br /> J <br /> [-DOMESTIC/PUBLIC IJ DRIVEN. .....:Gauge of-Cas(ng, <br /> L) IRRIGATION GRAVEL PACK �epth,of Grout Seal D i <br /> ❑ CATHODIC PROTECTION- ROTARY T <br /> - - Pe of Grout <br /> y - <br /> -. ❑,DISPOSAL ❑ OTHER Otl?er._lnformation- <br /> _.GEOPHYSICAL SurfaceSeal Installed By: C]f <br /> PUMP INSTALLATIQN: Contractor <br /> Type of Pump <br /> Pt3IVlf►=ITIFPL�IGEMEfdT: ❑ State Work DoneIV <br /> SUMP Arz" tR _-` _Stat lyork_Done. -� <br /> _ , - <br /> _DESTFLUQTIQ_ -0F WELL _- __ _Well-Diameter .. _.._ Approximate..Depth. <br /> _. _. <br /> .-.-..Describe MaterialandF'rncedure <br /> s , I,--hereby_certify that I hav-p;prepaMd-this.application atnd-that-4he•-work:wiil,be done in:accordance with San Joaquin.County - <br /> ondinances,state laws;-and.v- Aes and.regufations-of the San.Joaquin Local Health.District <br /> a .;; sNarn.eownerbrLice+ised:egei�i signe.hae:certigesthej'oII9wing:'1 cartifythat-inthe p6rformanue of4he work for which this permit <br /> Js ssued;,l,shalf not employr•arty person,in.such:manner,-as_to-7bet ome:subiect:to•w.orkman's-compensation laws of California." ' <br /> ContrActoYs-fiiring�orsub,contracting signalure-certifies the:foflowlag..`';l,certJty.that in:the performance of the work forwhich this <br /> permit,is issued, I shall:employ-persons sub)ect,to workman's compensation laws of California-".. <br /> _will call-fora' u1 r1ei cti or to-grouting and a final inspec#on. .. ` <br /> 9-. d X <br /> Si ne Title: x <br />- - Date. <br /> (Draw Plot Plan on Reverse Sid <br /> W....._ ,: Vf <br /> -.- FOR DEPARTMENT. SE`ONLY <br /> •-'. <br /> PHASE I . <br /> Application-Accepted-By _ bate. ` <br /> Additional Comments: <br /> - •' : :Pha e 8-Grout Inspection .:" a: /,P -111 Fina 'Inspection <br /> ' <br /> lnspectiloL Inspection By.v`/ r Date <br /> 'FCC 15,1�11e:-Lt ANNUALAN'Fl"' Q PER UNIT,.. "O;PER Zff -- ❑ EACH ❑ January 1 d,'Recened By January37- ❑ July 1 A Received By July 31 " <br /> REMIT <br /> �xPL1�ANATION <br /> BILLING REMITTANCE <br /> BASE S AMOUNT DUE3CHECKED <br /> DATE -DATE REMITTED `AMOUNT <br /> FEE <br /> LESS <br /> ..PRORATION ; <br /> PLUS <br /> PENALTY <br /> OTHER <br />' OTHER <br />�- Received by Date Receipt No. Permit No. Issuance Dale - Mailed 17elivered- <br /> APPLICANT—RETURN ALL COPIES TO; .- ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E_HAZELTON AVE-P.O,a0R x009 STOCKTO 95201 <br />