|
1lpptltatlans Will Be Prpcessed When Submitted PrFORoperly Cornpieteal. Be Sure To Sign The Apptit anon:
<br />OFFICE us£: APPLICATION
<br />_ _ .
<br />tr
<br />r. (For Non -Transferable, Revocable, Suspendabie)
<br />ENVIRONMENTAL HEALTH PERMIT� PUMP & WELL
<br />"LEiE IN TRIPLICATE} WATER QUALITY
<br />�.
<br />'m t5 isherehyrttadetot San Joaquin Local H#alth District for a permit to construct and/or install the work -herein described. This OPPlication is
<br />made in compliance with San oaquirt County t
<br />Exact Site Address iinanc , No. 18�2an a rules and regulations of the San i LO i Hsalth District.
<br />+1�+c]�-
<br />GitylTown ,"" "
<br />Owner's Name
<br />.._ — _
<br />_._
<br />Address Phone
<br />...� �.� ._. ,
<br />City —"
<br />Contractor's Name
<br />C ' _ L, .__._. License a:35 Y.Y_ Business Phomer... 'yam �j._ _.a 7
<br />Contractor's Address + -�-7 (.r- Eme en
<br />- rg , cY Phone
<br />is Certificate of Workman's Compensation insurance on File With SJLHD? Yes
<br />No
<br />TYPE Of WORK (CHECK): NEW WELL 0� DEEPEN 13 RECONDITION DESTRUCTION 0
<br />WELL CHLORINATION 0 WELL ABANDONMENT © OTHER © PUMP INSTALLATION❑ PUfiutl' REPAIR
<br />R EPLAt :EMENT © i
<br />DISTANCE TO NEAREST: Septic Tank Sewer Lines :
<br />_ Pit Privy
<br />_ Sewage Disposal Field CessPo01 Seepage Pit .�_�. Other
<br />Property Line _ _ _ .v
<br />Privets Domestic well ...:_,_ � __rrr
<br />. Public DoOstic Well
<br />INTENDED USE ._. TYPE OF WELL
<br />0 INDUSTRIAL �-CABLE TOOL " '
<br />$y,, Dia. of Well Excavation
<br />,$XvOMESTIClPRIVATE - © DRILLED• r --
<br />© DOMESTIC/PUBLIC Dia, o! Weli Casing _ _... _
<br />DRIVEN Gauge of Casing,
<br />d IRRIGATION---
<br />0 GRAVEL PACK
<br />Depth of Grout Seat
<br />© CATHODIC PROTECTION 0
<br />ROTARY TYJe of Grout
<br />11 DISPOSAL -•----- — ,,.__ _._
<br />OTHER Other Information -
<br />Cl GE13Pl iYSICAL ... .�'" ,..� 8urffhce Saal Installed
<br />PUNiIP INSTALLATION- Contractor
<br />YAa of PumpH.P...,....,_
<br />PUMP REPLACEMENT. © ------
<br />PUMP
<br />Stats Work Done_...... _ !t
<br />PUMP REPAIR: i d SWe Work Done °
<br />,TRUCTION OF WELL Well Diameter.... _,T.
<br />Approximate Depth
<br />..
<br />Describe Material and Procedure
<br />f i hereby certify that. I have prepared this application and that the work will be done in accordance with San 4caquin County t ,J
<br />ordinances, state laws, and rules and regulations of the San Joaquin Local Health District.
<br />r+ Home owner or licensed agent's signature certifies the following: "I certify that-lrl the psrformancebf 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 om
<br />1 Ixensation laws of California."
<br />Canfraciar a hkrir►g or sub -contracting signature certifies ttrs fati
<br />iowing. "I certify that in the performance of the work for which this
<br />.. permit is issued, i shall employ persons subject to workman's comp6nsation laws of CAlifornii:, ;
<br />I will fall for a Grout Inspection prior to grouting and a final inspection. � �--
<br />Signed X i
<br />T'itte:._..__-,���t.;' .-- _.` Dom , 77
<br />(Draw Plot Plan on Reverse Side) +
<br />PHASE I
<br />r
<br />J Application Accepted By
<br />Additional Comments:
<br />Ebii ti£#� RTMENT USE OtiLY
<br />Date .:'VA
<br />04Ms 11 xirout info» a _...._....� .�_.._.___.
<br />�"' PA It Final Ing n , ...
<br />Inspection 8y-_. . ' `, e '" �" Inspection By _ t .�
<br />•.__
<br />Fee IS till$: © ANNUALLY PER UNIT ©' anr,ary t ll Cin«. w a n„ ,i�W����i 7
<br />_ ,Pia:rt SiT�t-� ©'tr'ACt�
<br />LE
<br />PR
<br />PLP
<br />' 01'
<br />------------
<br />PSUMVed iy
<br />p,..,.._....._..__.:..`.5�...✓...��.....LtL'....._._.. /''•"""'.�.
<br />APP
<br />p — ormn No .�...__................_._,_...
<br />.� 15�uan�e Barr. Maltgtf np�ivorrel
<br />LiCAMT—hkti�fMlil,l►X.t� C17011r'9 TC,.ENWAONUENTAL HEALTH PrpM1T/4EpWC18. 1601 E. HAi'IELTON AVf.. p.(1- 80at WN STCSCXTON, CA 252lT1
<br />__. .......
<br />L-._ -,..
<br />,..,y , d
<br />_elv July as
<br />idASE,
<br />EXPLANATION ..
<br />81LLiNr r3PMIrTANGg
<br />� $
<br />tiErd IT
<br />""
<br />DATE DATE
<br />liEMi TEO
<br />R+tt7JNT LlL E
<br />CHECKED
<br />AMOUNT
<br />- 2+>
<br />OfiATiON
<br />LBS.
<br />NAL7Y"
<br />w
<br />,.,.,,�
<br />
|