Laserfiche WebLink
L Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) � qE �, <br /> PUMPP W <br /> & EL <br /> ENVIRONMENTAL HEALTH PERMIT FEB 210/ <br /> (COMPLETE IN TRIPLICATE) <br /> WATER QUALITY � � <br /> } Application is hereby made totheSan Joaquin Local Health Districtfora permitto construct and/or install the work hprleiiCPpspP�edh.This application is <br /> I made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San JoacpirE.W.ai�i'lv+4iSL Vh�l <br /> Exact Site Address�8 W. Country C:1 11 h Blvd . City/Town Stnl�t�t�Pr��^TED <br /> Owner's Name .ountry Cl tth Investors Phone-916-441-7 1 Q� <br /> I Address P ,Q _ 'Box ?7?;)4 City Sacramenf-n <br /> Contractor's Name Capitol–Pacific- Const . License# 32868__ Business Phone916-447- 1137 <br /> Contractor's Address 1 21 1 H Street Sar _ Emergency Phone . 9 16-4.41-7Y 16 O � <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN ❑ RECONDITION❑ DESTRUCTIONS <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 11PUMP INSTAL LiTTON'BUMP REPAIR 12 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> I Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line-.Private Domestic Well Public Domestic Well = _ <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ 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 Surface Seal Installed By: r <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. C <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done r <br /> DESTRUCTION OF-WELL: Well Diameter rt Approximate Depth <br /> Describe Material and Procedure _NIX OUP 7Vry UL:1 <br /> «I <br /> 1 I hereby certify that I 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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit r <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." C <br /> Contractor's heti or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit i ed I shall employ ersons subject to workman's compensation laws of California." <br /> 1 I r Grout Inspec' prior to gro g and a sinal inspectlo <br /> t Signed X Title: J► 44:z4l . y Date: <br /> (Draw Plot Plan on Reverse Side) <br /> 'FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted ByD ate <br /> Additional Comments: <br /> Phase II Gr ut Inspection Kase III Fin Inspection ,/ <br /> Inspection By Date Inspection B ate —/-'�-?d <br /> i. <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &ReceivedByJanuary 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> i BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> t - X <br /> FEE <br /> LESS <br /> PRORATION <br /> t PLUS <br /> PENALTY <br /> e OTHER <br /> OTHER , r]� <br /> y/ r O'er 5�--1 1 1 �7 <br /> Received by fifi7—attee Receipt No. Permh No. Issuance Date Mailed Delivered <br /> v4 -» <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />