Laserfiche WebLink
--- '�1^�••x ­••M­--a,,v v aign I ne Application, <br /> FOR OFFICE USE: APPLICATION <br /> •(for Non-Transterable„Revocable{Shapendable) - - <br /> r <br /> - <br /> `-k-"- ';"ENVIRONMENTAL,HEALTH PERMIT. 7 Y- 09:3 3 <br /> (COMPLETE IN TRIPLIt~ATE) f rf g'OO 0„ 14 C '"Wd TE/R�unuTY Q � 03-js <br /> Application is hereby made to the San Joaquin Local Health Dist ictfbrfYperrFilTtoconstruct and/or install the work herein�scrlhed,This applicaN'orr is <br /> made in compliance with San Joaquin County rdinance No.1862,and the rules and regulations of the San Joaquin ocat Honilh,District. <br /> Exact.Site Address e c <br /> -JJ CitylTown 10 4 , <br /> Owner'-s Name 5 J> r Yu~ <br /> Phone 6� � <br /> Ij Address ity L-a t, <br /> Contractors Name Qin ” , tib -License ill-C11)r-5� Business P.110 Y6 <br /> Contractor's Address rt �1 V.// <br /> Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD7 -Yes "" Noi— <br /> TYPE OF WORK (CHECK): ;NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION 11WELL ABANDONMENT 13OTHER ❑ PUMP INSTALLATIONS PUMP RE'PAIA11 <br /> REPLACEMENT❑ <br /> "DISTANCE TO NEAREST: Septic Tank 7 Sewer Lines s Pi!Privy <br /> Sewage Disposal•t=f eid Cesspool/Seepage Pit -Other_-- --- <br /> Property Line PtivateZomestic Well Public Domestic Well <br /> INTENDED-))USE TYPE OF VVELL <br /> ❑ INDUSTRIAL s°'' ❑ CABLE TOOL17 <br /> Dia.of Well Excavation 1'`� <br /> «0-DOMESTIC/PRIVATE ❑ZRILLED• r Dia.nof Well Casing <br /> DOMESTIC/P.USLIC _13 DRIVEN GauGaAA Casing -- <br /> '❑ IRRIGATION a ❑ GRAVEL PACK Depth.of.Grout Seat <br /> ❑ CATHODIC PROTECTION ®'ROTARY Type of Grout <br /> ❑ DISPOSAL s..;_ ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL t Surface Seal Installed By: p ! <br /> PUMP INSTALLATION: Contractor 41714 <br /> Type of Pump H.P. - <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Dvne ^� <br /> DESTRUCTION OF WELL-- Well Diameter Approximate Depth <br /> - Describe Material and Procedure <br /> I hereby certify•thaVl'have prepared this application and that the work will be done in accordance with San Joaquin County -P <br /> ordinances,state laws, and rules and regulatioTrs-of the San Joaquin Local Health District- z <br /> Home owneror licensed agent's signature cenlffes the lollowing:"I certify that in the performanci3 of the work forw4,Auh•thts-pvr(hit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laWabf California" <br /> Contractor's hiring or sub-eontractingsignature certifies the following:"I certify that in the performance of the work for.whlch this <br /> permit is issued, I shall employ persons-subject to workman's compensation laws of California." <br /> .' "'.t irfl!call orG t Ilion prior to grouting and a final inspection. (� <br /> Signed X. Title: 41 ^ '7 ?7 f <br /> (Draw Plot Plan on ReversDate: <br /> e Side) <br /> FOR O PARTME T USE ONLY <br /> .,PHASE I <br /> Application Accepted By-- Dlttu r <br /> Additional Comments l0• <br /> Phase 11 Grout Inspection <br /> inspection B Date — 5P ? Phase III Final InspecUni+ <br /> p y-..' � Inspection By Dale�gq '99 <br /> ­Fee Is Due: ❑ ANNUI0.LY-t, 1.3'PER UNIT ❑ PER$ITE " ❑ EACH ❑ .lanuary 1&Rece etl By January31 ',3�July 1 R Received By1u1y 31 <br /> } CHECKED <br /> BILLING .REMITTANCE REMIT <br /> a BASE EXPLANATION DATE � AMOUNT DUI: - <br /> DATE - REMf1TEb AMOUNT <br /> FEE ¢ <br /> LESS <br /> PSORATION <br /> PLUS t <br /> PENALTY <br /> OTHER <br /> OTHER �j JC.� Q } <br /> -57 <br /> O � /If— <br /> R9C@lved by Date Receipt No. Permit No. Iswance Date Maitea Dellveled <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA SS207 <br /> • v <br /> t <br />