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r-r`•a=rVrr5 vimtseProcessedWye Submitted Properly Completed B Sure <br /> � FORCFICE USE: — "_"`' •:r ,y-,�,� t <br /> { <br /> APPLICATION <br /> gn DEApplication.i <br /> C79 <br /> For Non-transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTF�PERMIT SAN J0A0WFLf0&fiEL i <br /> (COMPLETE IN TRIPLICATE) HEALTH DISTRICT <br /> Application is hereby made to the San Joaquin Local Health District fora permit QUALITY <br /> construct and/or install the work herein described,made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations ns the San Joaquin Local Health <br /> Exact Site Address 1 d 2�C? _ ed.This application is <br /> � ���� t District. <br /> Owner's NameL- City/Town 5 74 <br /> 5 i.c�,4t ry , <br /> Pj� <br /> Address jl�� r 1-�4n ,� Phone r7`7 'V d <br /> I Contractor's NameCity --T 7 <br /> • Contractor's Address License# 3�1�(�e{ Business Phone <br /> Emergency Phone 14(p if I q ItJ <br /> l Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 1 <br /> TYPE OF WORK (CHECK): NEW WELL❑ `k No I <br /> WELL CHLORINATION ❑ DEEPEN ❑ RECONDITION❑ No <br /> ❑ <br /> WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ <br />' REPLACEMENT❑ PUMP REPAIR❑ <br /> DISTANCE TO NEAREST: Septic Tank <br /> Sewer Lines Pit Privy <br /> Sewage Disposal Field <br /> Cesspool/Seepage Pit <br /> INTENDED USE Publi <br /> Property Line Private Domestic Well Other p <br /> c Domestic Well -i <br /> El INDUSTRIAL TYPE OF WELL <br /> 11DOMESTIC/PRIVATE 0 GABLE TOOL Dia. of Well Excavation L <br /> 0 DOMESTIC/PUBLIC ❑ DRILLED Dia. of Well Casing <br /> IRRIGATION ❑ DRIVEN Gauge of Casing <br /> CATHODIC PROTECTION 11 GRAVEL PACK Depth of Grout Seal <br /> ❑ DISPOSAL El ROTARY <br /> 13 OTHER Type of Grout <br /> ❑ GEOPHYSICAL Other Information <br /> PUMP INSTALLATION: Surface Seal Installed By: <br /> Contractor rl i <br /> PUMP REPLACEMENT: Type of Pump <br /> El Work Done H.P, <br /> PUMP REPAIR: ❑ <br /> DESTRUCTION OF WELL: State Work Done <br /> Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 /> Homeowner or licensed agent's signature certifies the following:'y certify that in the performance of the work for which this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California," <br /> Contractor's 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 employ ersons subject to orkman's compensation laws of California." <br /> will cal for a Grout In pe prior t grouti nd a final inspection. <br /> Signed X <br /> Title; ` <br /> (Draw Plot Plan on Reverse Side) Date' <br /> PHASE I F R D ARTMEN USE ONLY <br /> Application Accepted By <br /> Additional Comments: - Date A 1� 1 <br /> Phase II Grout Inspection - <br /> Inspection By Date µ Phase III Final Inspection <br /> Inspection Bycr.� Date <br /> Fee Is Due: ❑ ANNUALLY ❑ i PER UNIT El SITE ❑ EACH , <br /> 0 January 1 &Received By January 31 <br /> ❑ July 7 &Received BY July 31 <br /> BASE- EXPLANATION BILLING REMITTANCE _ $ REMIT <br /> FEE DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT i <br /> LESS 1 <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER �' I <br /> i <br /> O 3 5 s �D ` <br /> Received by DateI3 <br /> Receipt No. -�+- Permit No <br /> AppLICANT,RETURN OPIES TQ:- ENyIAONMENT tom;,_ Issuance Date Mailed Delivered <br />