Laserfiche WebLink
r <br /> •' 3 <br />, s <br /> -,'�r,r+onc Mill Be Processed When Submitted Properly Completed.Be Sure To Sigh The A00kollon <br /> ,( APPLICATIONS <br /> For Non-Transferable,Revocable,Suspendabte) a"{ <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITT <br /> Loc,r Health D st r ct for a permit to construct andlof install the work herein delufted.This application is x <br /> ,•:,i,w GcF,,nty Ordinanct,No i8b2 a d;he rules and regul icirts of the San Joaq%A L l aith District " s �0 <br /> 1 +� ' <br /> /A 0 1-.- ff S �Q Ll� ��►—..+Vi_. �iryJTown .---._J....,��..�w_�___ <br /> X41 C 66 �.f - — Phone r��_� <br /> License e _/ 7 -.BusinessPhone_ __ f- -7i.7.; k. <br /> 7 a �► ��d/t[v�wit !4• _ Emergency Phone <br /> n•4^,,a•fu Conivensahon Insurance on Fite With4LHD? Yes— „, -_ N �No <br /> `011K K NEw WELL DEEPEN © RECONDITION DE5TRtJC71ON❑ I <br /> ;u i4"ilOr ❑ WELL ABANDONMENT O1HER PUMP INSTALLATION❑ PUMP REPAIR If <br /> ':!BAREST. Septic Tank ---. Sewer Lines Pit Privy <br /> Sewage Disposal Feld .,- .- CesspoollSeepage Pit Other <br /> Property Line- _.-- ._ private Domestic Well—__ Public Domestic Well-_,_....___ <br /> 1.0t~D IISE TYPE OF WELL iy ' <br /> 17 CABLE TOOL Dia.of well Excavation -- <br /> PPIVATE ❑ DRILLED Dia.of Well Casing <br /> ;`.JEttJC ❑ DRIVEN I Gauge of Casing <br /> ❑ GRAVEL PACK Depth of Grout Seat <br /> C PRQTECT'rON ❑ ROTARY Type of orout - a <br /> ❑ OTHER Other lntormation -� <br /> ;,r�,�SrcAl i su tt c*Son:Instttl eyk <br />:Vi' INSTALLATION, Contractor -w�4+ <br /> Type of Pum Q -�_. ✓ i sem+. 1 H p 9 x i,b <br />!MP RC-PLACEMENT- ❑ State Work Done <br /> Work Done_ asp.��. !- y r qx <br /> 1fJ11� REPAIR: � 51ate 0 <br /> TRUCTION OF WELL^ Well Diameter_ '"�`, Approxltrtets � `" <br /> Describe Material and ProCeQuIB <br /> I rcereby certify that I have prepared this application and that ftWolk Mutt t*~.tn tooWdal MAtK'Son titin County t. <br /> ordinances,stale laws.and rules and regulations of the San do"utn Local F#falth Otstrtct r <br /> Home owner or licensed&pant"@ algnshlA certifies the%fle1i V4F"1 asirtify*0Ittthe of ths work for Mlf4leh thispermif� <br /> is issued, I shall not employ any person In such mar :r• : to beaol Subifti to IaicIrli riMt's-COMpeatattoh laws Of Calft mi& <br /> Contraetotrhltingorsubtont►ae"$%Ptth aOM esu laffolrlrl0 w.ceitlyshafthithisporkwiltarloeoflt+bworkforwhichthis <br /> permit is issued,1 shell employ persona subjaet t0 Wmat CatitorrN ," <br /> d IF <br /> I w I call for a Grout tnspeeft and a find bapeClioAB <br /> / a <br /> Toned XI TMc.- -- . Da1C _z <br /> (f]raw Pio Plan on Reverse Slide) <br /> { t <br /> It 0111PART&UM UN W&T <br /> F <br /> PHASE f a s . <br /> ApnricnilOn Accepted By57-- <br /> AMOIt anal <br /> Phaea It Grout tnspacNoi Phase tot IRM h ov -Ilbel <br /> Inshrctirn,syr_ Dau: . <br /> i <br /> Fre IS Our:0 ANNA ALLY ❑ptia UNil ❑PEn srrL ❑EACH ❑ J - 1 a pwaswed ev J*nuahi 3t ,.(3 July I a QoDrt+Aer ev Ju*31 <br /> __.. _ .. agLrM0 ALIMITTANCE AMOUNT 0a 1}/Mt o s <br /> 41 BASE exaL�NA*IVM PATE OAT@ FEW.W. - AMOUNT. <br /> 2 . L) <br /> ! _ ,"!, w. "'„• e,.u;e v n i hr,4jf',N t e %rs A'.OF At r,{, , slhrrt[; s t[aI a.r aftToa ask..Lo.a[[area aToeaTow,CA�t�s,.� <br /> wxt , <br />