Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> FOR O_ ..DICE USE: — APPLICATION <br /> /! p (For Non-Transferable,Revocable,Suspendable) <br /> / PUMP&WELL G <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER U J /OS—lL{D"- (8 <br /> (COMPLETE.INTRIPLICATE) ��a(o�p� 7Z A- QUALITY 7�1T��,, <br /> Application is hereby made to theSan Joaquin Local Health DQtrirr fore permitto construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and re�la�' o ui ye th District. <br /> Exact Site Address 0. a.-, _✓fid./ �..,,�,._ K./ �OO"'�ity rT rr <br /> Owner's Name Phone V7 -/S89 <br /> Address al we-owCity— <br /> Contractor's <br /> ity -� �y� 3 <br /> Contractor's Name .�J''b �r/+o,{y /11t�L Y„Sr.LLli�a License#2Q� 8'0Business Phone J o 7 <br /> Contractor's Address ,( - efa-.1112 C NIM S r Emergency Phoney^ <br /> Is Certificate of Workman's Compensation Insu ce on File With SJLHO? Yes No — <br /> TYPE OF WORK (CHECK): NEWWELLIDEEPEN ❑ RECONDITION❑ DESTRUCTIO,NO <br /> WELL CHLORINATION IJ WELL ABANDONMENT 11 OTHER ❑ PUMP'INSTALLA_TION LT PUMP REPAIR❑ <br /> REPLACEMENT❑ Al- ! _-�r pN <br /> DISTANCE TO NEAREST: Septic Tank 'i'�i� Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Properly Line 7Sr Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> t <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> 4DOMESTIC/PUBLIC C DRIVEN Gauge of Casing <br /> IRRIGATION 0 GRAVEL PACK Depth of Grout Seal <br /> ' ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER _ Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor5-4JtE-P <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <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. O <br /> Homeowner or licensed agent's signature certifies the following:"I certifythat in the performance of the work forwhich this permit -� <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 'i <br /> I will call a rout ction Nor groutin d a final inspection. C <br /> Signed X _ Title: Date: <br /> (Draw Plot Plan on Reverse Side) - <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By - Date�� a <br /> Additional Comments: ,e <br /> P ae 1 Grout Inspection rnL�aX �bydp ut •O�eY f Phase til Final Inspection <br /> Inspection By Date l'!�"�� Inspection By * �'�- Date L� <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January t a Received By January 31 ❑ July 1 9 Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE S <br /> BASE E%PLANATION DATE DATE RE1nFTEU7 AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE 1[ dE <br /> LESS <br /> PRORATION / f:C _ 0 <br /> PLUS <br /> PENALTY 0-aaw / �I v-,;,, <br /> ' � } <br /> ,a rNt h.u} S/-tM I - <br /> ...OTHER - J <br /> p I/d IC6.. . <br /> OTHER d I (r GI <br /> 1ob � g <br /> Received by -• Date Receipt Nm Permit No. Issuance Da[e Mailed Delivered <br /> z7 <br />