Laserfiche WebLink
A, <br /> r F•�`xtb e_s, <br /> r•.•ptiCations will Bn Processed When SubmittedProperty C <br /> ry T J - , ble,iFor Non <br /> R 1,5 <br /> ��g4 PP&ENYIHCNMFNTAL HEALTH PERMIT UM <br /> �AL r ' <br /> 1LO <br /> 'l; E <br /> 14 TRIPLICATE) WATER QUALM SAN Qy�fIRIV <br /> "'^...hV•r„idnlotheSan JoaiqunLocAlHealth D,sirictforapermit!OCDnstruWar►dr it� <br /> �Itwk heroin det�eribeq Ther apptitpll N <br /> :. k., } San Joaqurn County gt>:Luance No. 1862 and the ► les 7fntl regulations of tete Sate JnAinU1ft'L0qI Heallh Dlstrlov � <br /> A c+rp %�i'n �, dC City/Tawn -4 <br /> 1 -- �'�` .a.. Phone <br /> �. Ci �i <br /> / L i <br /> BUsI a - <br /> �AJy/L/yy/yam} _ � <br /> . Phone <br /> /�GrL._. Emergency Phone -_ <br /> 7 n 3i Workman's Gompensration Insta eon File ith WLHD? • Yes t No <br /> /// a. <br /> f <br /> OF WORK (CHECK) NEW WELL DEEPE4 REObNDIT101413 _ " DESTRUCTIOND �� s'� � <br /> CN'ORISVATtt7N ❑ WELL ABANDONMENT OTHER❑ t:` %r�#'`i, <br /> PUMP INSTALLATION© <br /> r ^JC.E <br /> TO NEAREST: S __ /_ �' r r. <br /> eptic Tank 2_J 1_ sewer Lines � t Privy . <br /> Sewage Disp I Field rid Pit / + <br /> PropertyLin%R r Priva - - , <br /> qre�,-��. ie Domestic Well �ybri r <br /> pJ�O�, c�stic�lfeii.- <br /> INTENDED USE <br /> S/� ' <br /> TYPE OF WELL ,• ., . ' <br /> VDI:$TR3ALCABLE TOOL Ofa,Of Wet1 FrtCavallon � I'1�. <br /> C7OMESTIClPRJVATE <br /> DRILI.f D Dia bt Welt Casing fi <br /> i C MESTIC:Pi1BL1C DRIVEN Gatipe of Casing <br /> 19RIGATION ❑ GRAVEL PACK Depth of Grout Seat <br /> r,47h'ODlG PROTECTION ❑ ROTARY � <br /> G THODI Type of GrW t <br /> ❑ OTHER _ Other Information , <br /> GEOPHYSICAL x PUMP INSTALLATION: COntrnco _ <br /> Q ` <br /> .---... .._. <br /> Type of Pump <br /> PUMP REPLACEMENT, ❑ State Work Do;.e. _ 0. <br /> PUMP REPAIR: ❑ State Work Dong � <br /> DESTRUCTION OF WELL Well Diameter - -r "�- ' 6 <br /> _ Approximate OepNl <br /> ry <br /> Describe Materiel and Procedure - <br /> I hereby certify that I have Prepered tills application and 00 e `work vr111 be dw*IR ac(XIII rtce with San Joaquin County <br /> ordinances, state taws,and rules and regulations of the San Joaquin Local Heatth District. a` <br /> Home owner or licensed agent's signature cenlfies ole fp{trllhW t sanity that#n th9pedormaf of thovvork for which This perms t <br /> is issued. I rhall not employ any person in Such manner"to Web"subject to+rorkinan'r Gompenaation fa1Rb of California." <br /> Contractoe s hiring or sub.Contracting elansture cartifi"ft k4eivA- "i OW611y OM In the performance of ft work tot which this <br /> Permit is issued, I shall employ persons subject to workntany OGrrlpenpatiOrl talcs 01 California:' <br /> 1 wt !1 a G Out Inspaetlon prior to grrsuting and a IMM <br /> 1 — _ _'a��.'� t_ — 11Nkguelf�s1 <br /> Signed XrDOM. <br /> ' Pr <br /> z, <br /> } <br /> USE 0ftV <br /> PHASE I <br /> R CEPA !!T � <br /> ApplitAtion Accepted By <br /> Additional Comments'.. -- Data <br /> -- � .,.w.-. <br /> . 1Phase 11 grouil IrlrpaeClort " Y <br /> Inspection By,,... VJ �� trtti gy- -i til (nspaell� <br /> tee to Due: ❑ ANIM)ALLv ❑ PER UVIT trPCn SITE I.]EACH ❑ J—_/d AmLo d By"n—y SI Q July 1 r Rx•Mawd Ay Jury it <br /> (aASf EXPLANATION REMMAOX* ! AST DUE Cr1ECttED a, <br /> .. ....- — G f GATE REMiTTEo - <br /> { <br /> A. <br /> da <br />