|
b - Applications Will 3e Processed When Submitted Properly Completed Be Sura To Slgn?The ApplfesElon.
<br /> FOR OFFICE USE APPLICATION �� ; ." 31982 _ y
<br /> {For Non-Transferable.Retrocabb,Suspendablel DUMP&WELL #
<br /> } -- ENVIRONMENTAL HEALTH PERMIT I fir, ' ��f!
<br /> Ty 1 OISTR CT L
<br /> WATER QUALITY '
<br /> (COMPLETE IN TRIPLICATE) t
<br /> Application is lie Il made to the San JoaquinLocal Health DFstnctfOra permit toconstruct and/or Install the work hereindtsserltted Thtsapptica �n`s��t�
<br /> _ made in compliance wi San Joaquin ounty Ordinance No 1862 and th les and regulations of the San aquln Local Hesllh DistriatYy
<br /> Y — CltylTown q 't rtk 2
<br /> Exact Site Address a..rr+ 1t4 -►�;
<br /> no -
<br /> Owner s Na ' t t,,
<br /> Cifyc
<br /> Address
<br /> Contractor sNam
<br /> - � r Emergr2ncy Phone _ _ ,i 'r�
<br /> Contractors Address No ry F�}
<br /> `li`1�gtr 0., Tryk _a
<br /> Is Certificate of Workman s Compensation Insurance on File With SJLHD� Yes�_ y _ iT�n ? fi "
<br /> TYPE Of WORK[CHECK) NEW WELL❑ !DEEPEN❑ RECONDITION❑ - DESTRUCTION❑ ��. � ,tii1�
<br /> WELL CHLORINATION❑ WELL ABANQONMENT❑ OTHER ❑ PUMP INSTALLATION PUMP FtEPI[TFta Y �'r}� r�
<br /> r E
<br /> ?~ REPLACEMENT❑ — z t v r
<br /> DISTANCE TO NEAREST Septic Tank Sewer Lines��- u1r c}
<br /> — 1 '' �' ar
<br /> Sewage Disposal Field Cesspool/Seepage Pit—��O•her--• it- <�
<br /> Private Domestic Well Public Domestic Well y n; f , 7t
<br /> f Property Line
<br /> TYPE OF WELL
<br /> r_ Y INTENDED USE
<br /> ❑~CABLE TOOL Die of Well Excavation-
<br /> 13
<br /> xcavation
<br /> ❑ INDUSTRIAL - - i
<br /> Q DRILLED Dia of Well Casing
<br /> ❑ DPMESTICIPRIVATE 13 DRIVE ! Gauge of Casing
<br /> &/DOMESTIC/PURLIC s < f 3 +tea r"3 ni '3! JrY r
<br /> a
<br /> ❑ GRAVEL PACK Depth of Grout Seat
<br /> ❑ IRRIGATION -T "df GrOUt r'wJ r" �r3` i'tillik,
<br /> ❑ ROTARY ype y y - rSf" Iks��` k
<br /> „4 r ❑ CATHODIC PROTECTION Other Information „
<br /> ✓vy ❑ DISPOSAL 13 OTHER
<br /> ," r ❑ GEOPHYSICAL - Surface Seat Installed By' ----
<br /> rF 1 r �fi r `,��7r '4s� tiyr�'Y�rR;7~k+rt
<br /> Contractor
<br /> yy PUMP INSTALLATION I x T HP
<br /> Type of Pump -• �Y' 13+` ,.�41�` S�'✓..'a
<br /> a PUMP REPLACEMENT ark Done E.t r, C,Yi. " liS{,
<br /> t' .ti State Work Dore _ ;a ,�
<br /> hh � DUMP REPAIR -„ Appraxima'e peptri "
<br /> F� DDESTRUCTIONOF WELL Well Diameter
<br /> [ ,Fr,r , " , r".o yi ix' •. ;� r'r
<br /> l Describe Materiaand Procedure
<br /> a
<br /> 'j° �•� I hereby certify that I have prepared this application and that the work will be done in accordancerw{ith San Joaquin Colye��Pill
<br /> 3ry h• M,r , �^ai cRC+'4JV24Ysi•""u',��,/,
<br /> r ordinances state laws and rules and regulatlons of the San Joaquin Local Health District f ,`v' 5
<br /> t� +^ Home owner or licensed agent s signature cerlilies the following I certify that in the performance of the work forwhich this permit v a
<br /> a } H issued I shad not employ any person to such manner as to become subject to workman s compensation laws`of California,
<br /> Contractors hiring orsub-contracting signature certifies the following !certify that m the performance of the workrt rwntch this -r,%;� , 41
<br /> a permit is Issued I shall employ persons subject to workman s compensation laws of California' *":�' =f� A , � #' � xi 1
<br /> titaM .0 I wi r a Grout Inspects rior 1 roulin nd a final Inspectlon
<br /> onto-,
<br /> Title
<br /> ' 1
<br /> �- Signed [Draw Plot Plan on Reverse Slde), 1 _ Y r-6 L,. - ,Df/
<br /> i
<br /> r--�
<br /> Y„r FOR DEPARTMENT USE ONLY
<br /> V * ✓ ' .'y�,''';' e ,.y it �;y.9�
<br /> PHASr 1 , t tv� Date a
<br /> • s Application Accepted y
<br /> 3> ^ _ #
<br /> Additional commentss jS
<br /> ' Phrout Inspection jrhsi�iiFinal spectlon
<br /> ��✓1 � I s+
<br /> Phase inspection By / r- �f Da e” s �<``• �
<br /> v lnsPe=Uon By :Date
<br /> � ' 3�7 r ve ''{��+�, .'.
<br /> rr� Fee Is Due ❑ ANNUALLY ❑ PER UNIT ❑ CO3EAC1 0, 41
<br /> H ❑ January 7 A Received BY January 31 ❑Jrly s�BjRecewd y Ju REMIT✓Iy 3j } �N 4
<br /> PER SITE
<br /> ♦ _ ^ BILLING REMITTANCE $ 't AMOUNT DUE w 't4°y h` rI
<br /> BASE EXPLANATION DATE DATE REM TTED -.. ,,.+ + t AMOUNT>' t, •it,
<br /> •rr ^'t� FEE � � � «+ + :� %�:-�+T�t�`�' '��'�� ��j` PGS i
<br /> LESS
<br /> "++ PROAATkt.N
<br /> PLUS ' + ++ r~_•k w .. +..r�/ti- >4✓tr„•,,:ylJ'a !
<br /> PENALTY r' +, f
<br /> Yat
<br /> ' xr OTHER
<br /> e, OTHER V t
<br /> r} +,, • , _ sauarr.� ete •r MaltedrOa1MW"11 1�p', .+i�Isjt' O �V
<br /> l
<br /> Date Racagt Na pill No -1, t
<br /> Recarrcd by Date &HAZlLTON AVE..P4 pea 2005 STLGtITON,GA!3261
<br /> APPLICANT—RETURN ALL COPIES TO' ENVIRONMENTAL HEALTH PERM'T+3ERYtCE3
<br /> ` �y - ,�,,,,_`.. w.... .. . .-...,r ... •,r e..... a , zti,'•^-fes!... .a.,.'C•; a 6✓fr...re���y4,�,�J t�'
<br /> u' Yr,
<br />
|