Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be qrv--blgn Ine tApplitamt1koll. 1 UJ <br /> FOR OFFICE USE: APPLICATION �A� 2 �98� <br /> (For Non-Transferable, Revocable, Suspendable) <br /> I PUMP &WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> SASN1 L X'AL <br /> 4 (COMPLEi'E.IN TRIPLICATE) WATER QUALITY HEATH DiS�TRiCT <br /> I Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> I made in compliance with San Jo quin Cou y Ordinance No. 1862 and the rules and regulations of the San loo n LI Health District. <br /> o' <br /> Exact Site Address d City/Town�.F� <br /> r Phone —'2-4q I <br /> Owner's Name <br /> Address City YYA CAry <br /> I License# IL��,�F_ Business Phone_+'Z�Contractor's Name - <br /> FEnver enc Phone <br /> Contractor's Address M��' <br /> � - Emergency <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL C3 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> t WELL CHLORINATION 11 WELL ABANDONMENT <br /> El OTHER E] PUMP INSTALLATION PUMP REPAIR❑ <br /> ' REPLACEMENT❑ ' <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> ►. INTENDED USE TYPE OF WELL <br /> f ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> s ODOMESTI G/PRIVATE <br /> ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> i ElCATHODIC PROTECTION 11ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> v ❑ GEOPHYSICAL Surface Seal Installed By: <br /> ,: <br />