Laserfiche WebLink
Applications Will Be Processed When Submitted Property Completed.Be Sure To Sign The Application. <br /> l FOR OFFICE USE:7 APPLICATION <br /> (For Non-Transferable,Revocable,Suspendable) <br /> PUMP&WELL 1 <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLIC_ WATER QUALITY <br /> A ppl icahon is hereby ma.ie to the San Joaquin Local Health District for a permit m construct and/or Install the work herein described.This application is <br /> made In compliance San Joaquin C my Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact S-te Add es 1474 N,.Yhornton Rd. City/Town (J- _. <br /> Owner's Name �` !/ �Q� y �}1Q)C.�y. (/�[,, C� Phone " <br /> Address _ 74 >2 9 ���Fjj 1�.��Xl� ). �h.Yel/� City 2� � <br /> Contre.ctor's Name �{�.j)-_ /�`-_—"'_"p_ _. .. License A�5 66� Business Phone '777. "�{L/ 3 w <br /> Contractors Addre,a G. L50,x Emergency Phone - <br /> ls OerhLoa:e of Workman's Compensation Insurance on File Wdh SJLHDn Yes No <br /> TYPE OF WORK (CHECK) NEW WELL 3 DEEPEN ❑ RECONDITIONDESTRUCTION❑ O� <br /> WELL CHLORINATION 0 WELL ABANDONMENT G OTHER 13 PUMP INSTALLATION ba PUMP REPAIR❑ <br /> REPLACEMENT ' <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines _. Pit Privy _ <br /> Sewage Disposal Fi PIG Cesspool/Seepage Pit Other _- <br /> Property Line _. _. Private Domestic Well Public Domestic Well _. <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL 0 CABLE TOOL Dia.of Well Excavation <br /> d <br /> O DOMESTIC/PRIVATE O DRILLED Dia. of Well Casing <br /> G4DOMESTICiPUBLIC 0DRIVEN Gauge of Casing <br /> ❑ IRRIGATION C GRAVEL PACK Depth of Grout Seal ? <br /> ? .C� <br /> � <br /> 13 CATHODIC PROTECTION 0 ROTARY Type of Grout rah r0•t.E.lfl ._ <br /> C DISPOSAL O OTHER Other Information - <br /> ❑ GEOPHYSICAL 5 utaco C -0✓ <br /> Seal Installed By: Cd rT-� 7 ___ <br /> PUMP INSTALLATION: Contractor_.�(J k'J � i�✓�A <br /> Type of Pump '._ S'� r�¢Y-.5/blt' ._ _ HP _.'.� _ .. .. ..J <br /> ^UMP REPLACEMENT: C State Work Done <br /> PUMP REPAIR: 13 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth ._. <br /> Describe Material and Procedure <br /> I hereb/ 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 regalatioh5 of the San Joaquin Local Health District. ---LL <br /> Home OW' r or licensed agent's signature certifies the following:-I certify that in the performAnce of the work for which this Parini, <br /> Is issued. I shall not employ any person in such manner as to become subject to workman's com; e- on laws of California." <br /> Contractors hiring er Sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> perm,t is Issurd. I shall employ persons suhlect to workman's compensation laws of California" <br /> 1 will call for a Grout Inspec on prior to grouting and a final inspection. <br /> ; "Ed X �,6� �h'7 ? r' {�••.,_ C—s ' Title: v�•swr•Yr Date: Lon 17 �yg( <br /> lDraw Plot Plan on Reverse Side) <br /> j FOR DEPARTMENT USE ONLY <br /> L, <br /> PHASE) <br /> nnn'.icaiinn AccrDlrn Rp Ul,)t�,� �Wuaa�. Oath <br /> ".nmi,oral (bmnv,lll`. <br /> Pha:.e II Grout Inspectionse III Final Inspeclicn Q/ <br /> Invp,•r.mn, !w Data Inspection By ,,.Phe <br /> Date '� j`�� <br /> Fee Is Due ❑ .. ❑ i In "1 ❑ iq i,.,i•e ❑ I Ar.,, ❑ Jamm'y t A 11 „, ,m ny J1n11m 11 J,e, i <br /> PEMIT <br /> HM1).NII i1E'AITTANCII s AMOUNT DUE CHEC✓FO <br /> 1.1 nNA,niN D11F GATE BEMITi/p AMOUNT <br /> K-7 <br /> SEP 0 1 1993 <br /> ENVIRONMENTAL HEALT <br /> � J <br /> / C-71 PERM IT/,'IERVICES <br /> n'IILS `'C FNyiae4l•SF`A: 4r Ai1HOrPMi15ENVtCFS RAI F. HAICLTUN AVEOCKT <br /> .PO 001 IGM SF <br /> ' )CNTON CA 95)p, <br />