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(For Nor.-Transiarable.Revocable,Suspendable) <br /> .'U..'i' '< V1FLL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct ardiorinstall me.vork nerein described.This application is <br /> made in compliance with S JOaq in County Qtdln39c:e No.1 62 and The rules and regulations of the c, n Lccal Health District. <br /> Exact Site Address yy-+ <br /> v ��l_--�----=/._ _. _ .. - City Tow.s� t^��0/v' <br /> Owner's Name <br /> F - -- .pQ�I_V(�.. Phone <br /> Address — - - /'�� /-- p - (• CrtY o -fD A/— <br /> C• <br /> R• Contractor's Nam/*,4 `�..y..�— License#3&0?,!S/ Business Phone <br /> a Contractor's Address a-R -���E�—O •��i�Z- "mergency Phonray�Y`/ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHDD Yes v No 1 <br /> TYPE OF WORK(CHECK): NEW WELLO' DEEPEN❑ RECONDITION DESTRUCTION❑ 1J <br /> WELL CHLORINATION❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank /70 Sewer Lines Pit Privy <br /> Sewage Disposal Field 7 O/ Cesspool/Seepage Pit Other <br /> Property Line.2p/- Private Domestic Well Public Domestic Well _ <br /> INTENDED USE TYPE OF WELL <br /> ❑ IN USTRIAL 13CABLE TOOL Dia.of Well Excavation <br /> DOMESTIC'PRIVATE ❑ DRILLED Dia.of Well Casing <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing _ <br /> 13 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal so <br /> ❑ CATHODIC PROTECTION 0'90TARY Type of Grout to.,- <br /> 1:1 <br /> DISPOSAL ❑ OTHER Other Information <br /> O GEOPHYSICAL Surface Seal Installed By.1 /V[ , P, S . //�•C• <br /> d - -- <br /> PUMP INSTALLATION: Contractor Pts -_ <br /> Type of Pump _—.__.. H.P. C.D <br /> PUMP REPLACEMENT: G State Work Done <br /> PUMP REPAIR: ❑ State Work Done - <br /> DESTRUCTION OF WELL: Well Diameter _ _ Apprf .,mate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws,and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following:g g g:"I Certify that in the performance of the work for which this permit 11 <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compent:Itlon laws of California." <br /> Contractors hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit Is issued, I shall emp arsons subject to workman's compensation laws of California' r I <br /> t; I call for a Gr c n pr r to grouting and a final Inspection. <br /> Si __ _ r �/ <br /> ( (Draw Plot PlanonRev side) � !"1+ Date: Y_ --�_ ._F <br /> G FOR DEPARTMENT USE ONLY <br /> PHASE I y (� <br /> Application Accepted By_ __ _____ ___.. _._ _-_._.. �"'�►�-G�- O Date <br /> kk Additional Comments: - <br /> ;1 Phase II Grout Inspection I` Mase IIIFinal Irippec�tion -- <br /> {h, Inspection By/� �-__ Date _T-2 3•�I- Inspection By :C(!+� 7 2a..' gef� te <br /> y Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January I a Received By January J1 ❑ July t 6 Recewed By July 91 <br /> --'-------- I ._.. - - -- - <br /> BILLING REMITTANCE— S REMIT <br /> f, BASE i EXPLANATION AMOl1NT DUE CHECKED <br /> r DATE 1i DATE REMI7TE0 AMOUNT <br /> - <br /> FEE <br /> VAX <br /> � <br /> LESS <br /> PRORATION � i <br /> � <br /> F ., ' <br /> PLUS r(�2 <br /> PENALTYV. <br /> OTHER <br /> OTHEH7/ 0 <br /> yt <br /> Recewed by Receipl No Permit Nu Issuance Date Marled thli.ered <br /> APPLICANT—RETURN A L DateCOPIES TO'. ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.HAZELTON AVE..P 0,Boa 2009 STOCKTON.CA W4201 <br /> E <br /> 177 <br /> ;f..., .. ..L '9. .- I.T. ) A.5 1 )?a•d ` <br />