Laserfiche WebLink
Applic ' Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FQA OFFICE USE: Rr APPLICATION I� <br /> (For Non-Transferable, Revocable,Suspendable)(`t�Gca C, <br /> t 1i t PUMP&WELL l <br /> ENVIRONMENTAL HEALTH PERMIT --- <br /> (COMPLETE IN TRIPLICATE) ,2-2. �,_/- I ER QUALITY 14A <br /> (COMPLETE !/ <br /> Applicationi'shereb mad t h anJoa inLocalHealthDistrictforapermittoconstructand/or, install the work herein described.This application is <br /> made in complianuin County Ordinances No, 1862 and the rules and regulations of the San J aquin oval Health District. t` <br /> Exact Site Address � LC 1t /• C� <br /> /f�J / City/Town �. <br /> Owner's Name/''il'�rt: /e k.Gz s!� /c-/C -ii <br /> Phone 5 <br /> Address 17 ' /C City <br /> Contractor's Name �la a GIC ,�� cense# JW/�_ Business Phone �! 6 <br /> Contractor's Address Emergency Phone 16k _/6_7 <br /> Is Certificate of Workman's Compensation nsurance on File Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION. PUMP REPAIR❑ <br /> REPLACEMENT❑ '' // y <br /> DISTANCE TO NEAREST: Septic Tank A/e Sewer Lines D!� Pit Privy ecOA'e- <br /> r <br /> Sewage Disposal Field �� Cesspool/Seepage Pit 10A10-- Other V16 <br /> Property Lined Private Domestic Well,& & Public Domestic Well +J L/-e-- <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ABLE TOOL Dia. of Well Excavation s <br /> ;DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> El IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> 1 <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout G A/ <br /> ❑'DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL -- J ,Surface-Seal Install By: ` f�,�`r" ` <br /> PUMP INSTALLATION: Contractor G�!L� �G V 11G�, �� •� + �' 4e 4Z gyp, <br /> Type of Pump csu.l 6 H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done �} <br /> PUMP REPAIR: f ❑ State Work Done' � \ <br /> DESTRUCTION OF WELL: 'Well Diameter <br /> Approximate Depth <br /> ,,,Describe Material-and Procedure <br /> 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 /> Home owner or licensed agent's.signalure certifies the following:"I certify that in the performance of the work forwhich this permit <br /> 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 or 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 wor'kman's compensation lawS of California." <br /> I I call for a Gro ins ection prior to grouting and a final inspection. ' <br /> Signed Title: Date: ,l <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY f <br /> -'PHASE I <br /> Application Accepted By Date _.S.Z_�� <br /> Additional Comments: <br /> A -se II Grout Inspection Phas II Final Inspection r <br /> Inspection By42UI041E Date Inspection By Da/te�-�/r <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 LJ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE i <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> w <br /> Received by ate - Receipt No. Permit—Ko.' Issuance Date Mailed Delivered - - , <br /> k <br /> ' "APPLICANT—RETURN-ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />