Laserfiche WebLink
N.ppuL.aulnu rnrl ur rrucrssru uuelr ouuuuuru rwpc.rr wo�Nm.cu. ..0 ..0/4, �lyu f�., r Xv............. <br /> FOR OFFICE USE: APPLICATION <br /> (,axion-Transferable,Revocable,Suspeid>f e]--' <br /> '' II PUIWELL <br /> "Lpi� <br /> ('' <br /> ENVIRONMENTAL HEALTH PE NOV I <br /> DMPLETE IN TRIPLICATE) WATER QUALITY 9 1980 <br /> yapl ication is hereby made to the San Joaquin Local Health District for a permit to construcland/ot3'RINII Tnw ll)hIeip Described.This application is <br /> Hilda ulations <br /> 9de in compliance with San Joaquin County Ordinance No. 1862 and the rules and re �1 RCt'eLSIo <br /> U_W qL�6pl'I4eallh District. <br /> act Site Address IZ4-10 E G RO City/Town IJ l h(Vr <br /> *inners Name U.S. GR5fl, I - r MNL. Phone <br /> ddress—t ,0• CL Lt7 N City LbC.LJ2-FAl2Q <br /> ntractor's Name QDC-H,RLNl� PUMP License#�C1 I Business Phone1Z7-S54R 0 <br /> `ntractor's Address-PZ-3-AD.Iok I(Br I CXAtG =r:Q0 ` Emergency Phone 1 <br /> Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> "PE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION DESTRUCTION❑ •�I <br /> :LL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> ArrPLACEMENT❑ 2 PU.rr r�y <br /> ]STANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> r Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casi}g <br /> DOMESTIC/PUBLIC - ❑ DRIVEN Gauge of Casing <br /> IRRIGATION 1 ❑ GRAVEL PACK Depth of Grout Seal <br /> CATHODIC PROTECTION - ❑ ROTARY Type of Grout <br /> lue DISPOSAL OTHER`. Other Information <br /> GEOPHYSICAL Surface Seal Installed By: <br /> IMP INSTALLATION: Contractor <br /> _ ype of Pump H.P. <br /> UMP REPLACEMENT: ❑ State Work Done PumP01— 15hn-IL_�rbine-n&U 1 ,L 1A +LID P AIS1 - <br /> "IMP REPAIR: ❑ State Work Done{•U"02-30hn fLk-hLtX-.it6l,0 VDWIJ *- ZO S-t, ZV.Pirimlen <br /> :STRUCTION 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 /> r ordinances,state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the•performance of the work for which 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- onlracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> r permit is ss , I shall employ persons subject to workman's compensation laws of California." <br /> III rCLt`Y <br /> I '1 a G ul Inspection prior to grouting and a final in n. <br /> Ined X r _ Title: _ Date: <br /> r (Draw Plot Plan on R verse e) "f9 <br /> 1 <br /> FOR DEPARTMENT USE ONLY (�y.� rQ•116J-�-'+� 1 W <br /> PHASE I �� J � `-O IG <br /> r Application Accepted By wr /Date.? <br /> Additional Comments: <br /> Phase 11 Grout Inspection Ph e I r trial Ins.ention z (c <br /> r Inspection By Date Inspection By — to <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE S <br /> lee EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE S / <br /> LESS <br /> r PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> r <br /> OTHER pp CC�G� p T <br /> OOW 1 I � I D V <br /> Received by • Date Receipt No. Permit No. sauanw Date Mai1e0 Delivered <br /> AM WANT—RETURN ALL COPIES TO•. ENVIRONMENTAL NFAI IN PFAMO/AFIIVICFR 1411111F NAM Tn.AVP on b..911110 RInI.Tn. fA a{prlt <br />