81-268 - Laserfiche WebLink

Home Browse Search

f;- Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION '� �f, � (Por Non-Transferable, Revocable, Suspendable) ENVIRONMHH ENTAL EALTPERMIT pe PUMP&WDLL ' (COMPLETE IN TRIPLICATE) �iV^ WATER QUALITY Application is hereby made to the SA4JXquinLocal Health District fora permit toconstruct and/or install tkhereindescribed.Thisapplicationis made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. ' Exact Site Address 3 4 r City/Town _`Ar, _,Py Owner's Name :PLLAME louch6YM7— Phone 3 —71 r Address v City Contractor's Name 6JA9601V License Business Phone 3 7 Contractor's Address 770 ea.x [� ADV Emergency Phone 759— Is Certificate of Workman's-Compensation Insurance on—File—With SJLHD?_Yes No TYPE OF WORK (CHECK): NEW WELL DEEPENR CE ONDITION DESTRUCTION ❑ WELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER ❑—PUMP INSTALLATION ❑ PUMP REPAIR C3 REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank (46- Sewer Lines (o . Pit Privy Sewage Disposal Field Cesspool/Seepage Pit - Other Property Line Private Domestic Well Z2 Public Domestic Well a s INTENDED USE TYPEOF WELL h ❑ INDUSTRIAL CABLE TOOL't Dia. of Well Excavation !� 105-T ' "pf bOMESTIC/PRIVAT 0-DRILLED Dia. of Well Casing ❑`DOME$TIC7PUBLICo"- ❑ DRIVEN Gauge of Casing r ❑ IRRIGATION ❑ GRAVEL PACK.,. ..„ ,"Depth-of Grout Seal � ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout I ❑ DISPOSAL ❑ OTHER Other Information "�� ❑ GEOPHYSICAL Surface Seal Installed By: L.LJ t PUMP INSTALLATION: Contractor BLS= '�/�� , .ems ;W��L._ Wi:99! Type of Pump H.P. or 7 PUMP REPLACEMENT: ❑ State Work Don PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County I ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. O1j Home owner or licensed agent's signature certifies the following:"I certify that in the performanceof the work forwhich this permit O; l is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." I Contractor's 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." f I will ca fora Grout Inspection prior to gr uting and a final inspection. r� Signed X Title: Date: (Draw Plot Plan on Reverse Side) a FOR DEPARTMENT USE ONLY PHASE i Y. * � ( Application Accepted By Date7111 11 L l k( Additional Comments: P s I Grout Inspection a II f=inal Inspection Inspection By Date 'n Inspection By Date r I IF Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 R Received B REM By July 31 I BILLING REMITTANCE $ BASE EXPLANATION DATE DATE REMITTED - AMOUNT DUE CHECKE ` C,4"",, AM T FEE LP LESS r PRORATION s' PLUS PENALTY OTHER OTHER ��{) Received by Date Receipt No. Permit No. - Issuance Date Mailed De! eyed "APPLICANT—RETURN ALL'COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201.