Laserfiche WebLink
Appli nsViil Be Processed WhennIPPLICATION <br /> itted Properly Completed. tae sure Iosign IneAPPIIUMMrr• <br /> p� i� Teta <br /> FOR OFFICE USE: MAR 2 J <br /> # [YI !�J (A Non-Transferable, Revocable, Suspendable) / � x k kisl PUMP&WELL <br /> , ,NIE"kV4i -CL MENTAL HEALTH PERMIT <br /> il , �{COMPLETE IN TRIPLICATE) HEA TI i DlS�ti,C WATE�t QUALITY <br /> Application is hereby LICmadthe San Joaquin Local Health Districtfora permitto construct and/or install the work herein described.This applica <br /> made in compliance with San Joaquin Coun Ordinance No. 1862 and the rules and regulations of the San Joaq ` Local Health District, <br /> Exact Site Address �sf'?t Im p - 3 a City/Town <br /> Owner's NameIk �� Phone <br /> I li Ydo City �O ' <br /> Address <br /> Contractor's Name IturvIance Dri ers Dri i Corp, License#377 923 Business Phone__ - <br /> r q� - L ' Emergency Phone <br /> Contractor's Address r7 ,� h 9 Y --- - <br /> Is Certificate of Workman's-Compensation Insurance on File With SJLHD? Yes No Ob <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ �l <br />+ WELL CHLORINATION ❑ W`ELL ABANDONMENT 11 OTHER ❑ PUMP INSTALLATION J29 PUMP REPAIR <br /> REPLACEMENT❑ II <br /> DISTANCE TO NEAREST: SepCtic Tank Sewer Lines Pit Privy <br /> Se age Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE I ' TYPE OF WELL <br /> ❑ INDUSTRIAL I ❑ CABLE TOOL Dia, of Well Excavation <br /> k ❑ DOMESTIC/PRIVATE I ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ! ❑ DRIVEN Gauge of Casing <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL I Purviance Drillers DAMV .al Installed By: <br /> PUMP INSTALLATION: I Contractor <br /> Type of Pump <br /> 1�Yh1h Q" H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> ❑C State Work Done PUMP REPAIR: .- - b -_*'- .. - - I Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> ' I Describe Material and Procedure <br /> X <br /> I I hereby certify that Il.have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin-Local Health District. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> k is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring o i�sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject-to workman's compensation laws of California." <br /> I will call for a rou nsp tion prior to-grouting and-a final inspection. <br /> �' ,.. �.. Date: 3-- -,P/ <br /> Signed X l Title:: <br /> I (Draw Plot Plan on Reverse Side) <br /> .tib S <br /> i FOR DEPARTMENT USE ONLY A <br /> C PHASE I 1 <br /> Application Accepted By � `-� � Date <br /> i PP p <br /> E Additional Comments: <br /> Phase I Grout Inspection .F - Phase III Final Inspection <br /> Inspection By 'I. Date - % - Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY l ❑ PER UNIT_ ❑ PER SITE El EACH ❑ January 1 &Received By January 31 El July 1 &Received By July 31 <br /> ' y <br /> -REMIT <br /> �!• BILLING REMITTANCE $ AMOUNT DUE .CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT f <br /> I . <br /> FEE <br /> .I <br /> LESS i <br /> PRORATION IM. <br /> } PLUS <br /> PENALTY <br /> OTHER �I + <br /> OTHER. <br /> r <br /> Received by Date Receipt No. Permit No. s uance Date Maifed Delivered <br /> A 95201 <br /> APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH.PERMITlSERYICES 1601 E.HAZELTON AVE.,P.O.Box 2004 STOCKTON,C <br />