80-89 - Laserfiche WebLink

Home Browse Search

1 Applications Will BI!Processed When Submitted ProperlyCompierea. I sure 1uoryrr •�;err �- Y APPLICATION FOR OFFICE USE: " { (For Non-Transferable,,Revocable, Suspendable) ,. PUMA&W)=!L 'w ENVIRONMENTAL HEALTH PERMIT `€ �. WATER QUALITY _ (COMPLETE 1 TRIPLICATE) Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is made in compliance wit o quin Count Ord nce No. 1862 and the r es and regulations of the San Joaquin Local Health District. c City/Town Exact Site Address ;9 X, Phone Owner's Name City '# Address Business .. License# Business Phone_ Contractor's Name Contractor's Address 3 ' a -re- �-^ Emergency Phone , Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_X No TYPE OF WORK (CHECK): NEW WELL DEEPEN C1 RECONDITION 11DESTRUCTION❑ ; WELL CHLORINATION 13WELL ABANDONMENT 11OTHER 13PUMP INSTALLATION 11 PUMP REPAID REPLACEMENT❑ r Pit Priv DISTANCE TO NEAREST: Septic Tank Sewer Lines y Cess ool/See a e Pit Other Sewage Disposal Field p p g � Property `ine Private Domestic Well Public Domestic Well TM i T INTENDED USE TYPE OF WELL ❑ INDUSTRIAL I� ❑ CABLE TOOL Dia. of Well Excavation f ❑ DOMESTIC/PRIVATEII ❑ DRILLED Dia. of Well Casing 11DOMESTIC/PUBLIC ElDRIVEN Gauge of Casing i IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 13 CATHODIC PROTECTION �� El ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information r 11 GEOPHYSICAL �`�` Surface al Installed By: t I IIs ��fi? 1 PUMP INSTALLATION: �. Contractor � � Type of Pump 's H.P. PUMP REPLACEMENT: ❑ State Work Done P a PUMP REPAIR: I ❑ State Work DoneI DESTRUCTION OF WELL: Pit— Well Diameter Approximate Dept 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- ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. r k Home owner 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." It 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." �. I wit all for a Gro pection prior to grouting and a final inspection. Title: �L�. ' Date: Signed X ' r I� (Draw Plot Plan on Reverse Side) I` FOR DEPARTMENT USE ONLY I� PHASE I I� Date Application Accepted By Additional Comments: j Phase II rout Inspection Ph Ole 111 Final Inspect! ' Inspection 8y i� Date Inspection By I i ' ❑ PER SITE ❑ EACH ❑ January 1 Received By January 31 El July 1 &Received By July 31 Fee Is Due: El ANNUALLY El PER UNIT REMIT II BILLING REMITTANCE $ AMOUNT DUE CHECKED BASE EXPLANATION DATE DATE REMITTED AMOUNT ' r i FEE LESS Ii PRORATION PLUS PENALTY OTHER I II I. OTHER Permit- o. Issuance Date Mailed Delivered �" � N Received by Date I Receipt No. ' 1601 E.HAZELSON AVE.,P.O.8o�c.2008 STOCKTON,CA 9 07 APPLICANT=RETURN ALL COPIES TO: -ENVIRONMENTAL HEALTH PERMIT/SERVICES _ - ..