SU0007395 SSNL - Laserfiche WebLink

Home Browse Search

^PPv..vumra Win oe rrUUe55eU rvnen oubmmeo rroperly l ompleled. ue Sure 1'Q.DFOR OFFICE USE: APPLICATION �J i 't" j �j (For Non-Transferable, Revocable, Suspendab-, _u p��qq� J Ufa �t1PAAWIELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY .`�i.�-N J-. "r'V ( 0'7TALL �Application is hereby madeto the San Joaquin Local Health District for a permit to construct and/or install the work4 riihdescae-d ITjFi"4 plicationis made in compliance with San Joaquin Coynty Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address :.V 29 37 N,'c/c� City/Town Owner's Name ��',�? 1��9��X-S?il/ Phone 17/ "l G'.Z7 Address n 3 5/ �/, 5"� /ia wi /t s eic k ��s( city� �i/7 }end 5;1.5-it ri" Contractor's Name1.t�ot,:�; W/� 7__ License#.� 2 SQL( Business Phone ':»✓5 -7�//.' -1 .Contractors Address//YS�� $,, mrr��✓��N JP� /y/,emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHO? Yes No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ r WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 13 PUMP INSTALLATION PUMP REPAIR REPLACEMENT❑ /n DISTANCE TO NEAREST: Septic Tank :5:c Sewer Lines f j"C Pit Privy V Sewage Disposal Field Cesspool/Seepage Pit Other Property Line C�L' Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL �r CABLE TOOL Dia. of Well Excavation / 5� . 41.-f DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout .5..:.,. zzl �ruic.e T r❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL � � / Surface Seal Installed By: Weh 4; PUMP INSTALLATION: Contractor YK/�/- 4 Type of Pump ti �rvFs, j)! H.P. 157 PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done p� ✓DESTRUCTION OF WELL: Well Diameter Approximate Depth 1_ Describe Material and Procedure V' I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Z ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California," Contractors hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." I will call for ay�Grout /Inspection prior to grouting and a final inspection. `Signed X Title: eery IT&, It,y Date: 6+ 'j " r3/ (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY j� PHASE 1 Ll �1 Application Accepted By © Date b'�'81 E Additional Comment tl Pht, It Grout Inspection h III Final Inspection SII Inspection By Date Inspection By Dat !R.cm.11Fee Is Due: ANNUALLY 11 PER UNIT PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July y July 31 REMIT BILLING REMITTANCE $ BASE EXPLANATION AMOUNT DUE CHECKED a DATE DATE REMITTED AMOUNT FEE LESS PRORATION PLUS PENALTY ` OTHER — OTHER ale Received by Receipt No. Permit Na. Issuance Dale Mailed Delivered •vm rreur—vmrvu a orae rn. auvrvnumur.r u