Laserfiche WebLink
.. <br /> r- <br /> Y - Applications Will Be Processed When Submitted Properly Completed.B"rq a Application. <br /> FOR OFFICE USE: APPLICATION, s*10 rL11] \ <br /> (For Non-Transferable,Re/v jbeus le <br /> ENVIRONMENTAL F' kE L\L% H PERTI T 19�� PUMP&WELL <br /> I (COMPLETE IN TRIPLICATE) WATER QtI �\O)N S ^1- <br /> f Application is hereby made to the San Joaquin Local Health District fora permit t eonsbuctand/origsts�,thbGdiITherein described.This application is <br /> made in compliance wit q e uin �',nt O'rdJ^ance 1882 the rules entl re PI or'r>:E, uin Local/�allh Dis t.l / <br /> Exact Site Address_ ��i�� '/i'/L � G_ CJ�\� 6' oN,n Lam( <br /> Owner's Namgr"� S Phone�0 <br /> Address �l y_ 7�' _--- <br /> `.; Contractors Name 3..�C— /L 1 License a'37�usiness Phone AZ 7_��_✓ _ <br /> >e— <br /> Contractor's Atldress / /_ 07 . Emergency Phone —T <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHO? Yes No <br /> TYPE OF WORK(CHECK): NEW WELL® DEEPEN O RECONDITION❑ DESTRUCTION❑ ) <br /> WELL CHLORINATION O WELL ABANDONMENT O OTHER O PUMP INSTALLATION ly PUMP REPAIR O <br /> REPLACEMENTO . 1 <br /> DISTANCE TO NEAREST: Septic Tank —,6,24 Sewer Lines / r Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other r- <br /> Property Line Private Domestic Well_ Public Domestic Well <br /> INTENDED USE TYPE OF WELL / <br /> O INDUSTRIAL O CABLE TOOL Dia.of Well Excavation A5? <br /> ©IDOMESTIC/PRIVATE O DRILLED pia.of Well Casing 6 <br /> gi O DOMESTIC/PUBLIC O DRIVEN Gauge of Casing <br /> t O IRRIGATION O GRAVEL PACK Depth oi Grout Seal <br /> i O CATHODIC PROTEC71ON 3.11OTARY Type of Grout <br /> Il O DISPOSAL O OTHER Other Information _ <br /> ESF O GEOPHYSICAL �j Surfac eal�InStSgEdd _ <br /> PUMP INSTALLATION: Contractor_v T� yMI� <br /> i <br /> Type of Pump H <br /> ODone___ <br /> _-- . <br /> [Ikj PUMP REPLACEMENT: State Work Dona _ <br /> ❑ <br /> PUMP REPAIR: State Work Done � <br /> DESTRUCTION OF WELL: Well Diameter -- _ Approximate 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 /> Homeowner or licensed agent's signature certlfles the following:"I certify that in the performance of the work for which this permit <br /> is Issued shall n mploy any person in such manner as is Become subject to workmacompensation laws of California." <br /> Contractors I n's g or rub-cont signature certifies the following: 1 ca hat in the performance of the work for which this <br /> .per - Is SIT empl y perso subject to workman's componsa laws of California." <br /> will c o Inspecll prior o grouting a J a final Inspecti <br /> Signed X _--- . o ._ _ _- . - <br /> Title: <br /> —__ Data: <br /> (Draw Plot Plan on Reverse Side) - <br /> yA�����`4`p� �FOR�D�EPARTMENTT USE ONLY <br /> PHASE I _1 1 '�K.. —..__�•V_`MA.©v__-_._ _-. __ _ .. _ 1 �ynt O-+ <br /> APPlicelion Accepted By __ - _. Dale ,�_-1_ <br /> r Additional Comments:- <br /> ase I Grout Inspection net Inspection <br /> Inspection B `� __-_ Date. ��.,S�p,. Inspection B Date .131"vj=D 1-._._ <br /> Fee I!Due:❑ /v .-ALLY ❑ PEn UNI_ ❑ PER SItE _ ❑FACII ❑ Janvny 6 ecnnea ay January b 0 Juty I a Rece erl By July 31 <br /> BILLING REMITTANCE ! REMIT <br /> BASE EXPLANATION DATE i DATE REMITTED AMOUNT DUE CHECKED <br /> r - -0'O- AMOUNT <br /> EEE . -S <br /> LESS - - - <br /> PRORATION <br /> PLUS <br /> vENaliv <br /> OT R <br /> II <br /> OTHEN ( DrNSLI _.. <br /> Rece'm by Dew naart,l Nn --',I No � �s�ace Dll�� Me�eA poerereE --- <br /> 1PPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT-SERVICES IIII E.MA2[LTON AVE..P 0.Boa Na! STOCXTON,CA o! <br />