Laserfiche WebLink
A11'ianfs Will Be Processed W 1�+ ubmitted Properly Completed:Be Sure To Sign The Application. <br /> FOR OFFICE USE: <br /> -MAWill <br /> - 8 1982 APPLICATION <br /> {: (For Non-Transierable, Revocable, Suspendable) <br /> C PUMP&WELL <br /> SAN JOAQUIN L(J&41RONMENTAL HEALTH PERMIT <br /> �H:EALTH DISTRICT <br /> . <br /> + (COMPLETE IN TRIPLICATE);' WATER QUALITY <br /> Application i5 hereby made to the San Joaquin Local Health District for a permit to 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 regulations of the San Joaquin Local Health District. <br /> Exact Site Address 1l City/Town � t <br /> Owner's Name �h I e rr,ea r, Phone 577—Z101 <br /> Address !�. • 1c,14011 R.L <br /> City <br /> Contractor's Name S d-V License# Business Phone <br /> Contractor's Address 5a-,gm Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No ✓ <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTIO�N❑ <br /> ( WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ SI PUMP INSTALLATION!'°') -,PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 11 Z5 Sewer Lines l50 Pit Privy <br /> I'. <br /> Sewage Disposal Field esspool/Seepage Pit- - Other--- - - - <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> f ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 19 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> 1 ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> f ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP lNSTALLATIO Contractor S e 17C <br /> (Type of Pump GoitCelfs :5"rne_S; telt H.P. <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 /> K <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 /> Homeowner 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 shalt 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 villi call f r a G.Louj Inspection prior to grouting and a final inspection. P <br /> Signed X . + " : ' Title: d W!Icr _" Date: 3- 3- V2- <br /> (Draw <br /> — 3-- V2(Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted Byk'�AlDate <br /> Additional Comments: <br /> Phase 11 Grout Inspection base II Final Inspection <br /> r Inspection By 0 Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> i BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> .FEE �'9� <br /> LESS <br /> PRORATION <br /> 1 PLUS <br /> PENALTY <br /> OTHER <br /> pF OTHER <br /> k I^ <br /> I Received 6y I Dat Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN-ALL'COPIES-TO: .ENVIRONMENTAL HEALTH PERMINSERVICES 1601 E.14AZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />