Laserfiche WebLink
Application's Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION a-1z _tx�1 5 le /. <br /> µ (For Non-Transferable, Revocable,Suspendable) it. � <br /> i ENVIRONMENTAL HEALTH PERMIT PUMP&WELL+ <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY, E � a <br /> 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 <br /> made in compliance with San JoagIbIin County Ordinance No. 1862 and the.rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 1026 Z�L N 1 City/Town <br /> Stockton <br /> Owner's Name Harold Phone <br /> .477-4712 <br /> Address ii City <br /> Contractor's Name Moorman! t License#2�7_69Fs, Business Phone _32.10 O4 <br /> Contractor's Address x.243 ChIl-r_r_y land AVP. Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes x No <br /> TYPE OF WORK (CHECK): NEW WELL 9 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION IJ ELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ i / <br /> DISTANCE TO NEAREST: Septic Tank ! �® Sewer Lines l�t- Pit Privy <br /> Sewage Disposal Field-/ Cesspool/Seepage Pit Other <br /> Property Lin ?A� Private Domestic Well_15 Public Domestic Well 1f � <br /> INTENDED USE � TYPE OF WELL <br /> ❑ INDUSTRIAL ! i ❑ CABLE TOOL Z_ /th <br /> ,,��,, Dia. of Well Excavation <br /> ® DOMESTIC/PRlVATE Wf 1 RILLED Dia, of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN - Gauge of Casing Ile 14 [ ' <br /> ❑ IRRIGATION ❑, G �. <br /> ..GRAVEL PACK �_ �"'Depth of Grout Seal <br /> 1-1CATHODICPROTECTION IK ROTARY'"'"`" Type of Grout �t <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 13 GEOPHYSICAL Surface Seal Installed By: r <br /> PUMP INSTALLATION: Contractor Moorman,' s Water S stems <br /> � I <br /> Type of Pump submersible H.P. I <br /> PUMP REPLACEMENT: ❑ State Work Done. <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: i Well Diameter pproximate Depth �-;- <br /> Describe Material and Procedure S_� f <br /> 6.e . u s' ,r e 7'n r�r . <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 signature certifies the following:"I certify that in the performance of the work for which this permit1 <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 sup-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 wi all for a Grout Inspection prior to grouting and a final inspection. y <br /> Signed X !r Title: t.P�L./ Date: <br /> �i (Draw Plot Plan on Reverse Side) <br /> dam! FOR DEPARTMENT USE ONLY J'1,5/0/,(" lam✓eeyl 6,1--; P< <br /> PHASE <br /> Application Accepted By ' i e %� _ —� <br /> Date <br /> Additional Comments: <br /> RJ%pseil,1 Grout Inspection se III F'nal Inspection <br /> inspection By II` Date �� �� inspection By Date <br /> Fee Is Due: ❑ ANNUALLYr❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By.January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> .I <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> E <br /> LESS I � <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER `6 <br /> OTHER li�l <br /> 'dI! �� B s <br /> Received by Date 9� Receipt'No. Permit No. Issu nce to Mailed Delivered <br /> < <br /> APPLICANT—RETURN ALL COPIES PTO: ENVIRONMENTAL HEALTH PERMIT/SERVICES'' - 1601 E.HAZELTON AVE.,P.Q.Box-2009 STOCKTON,CA 95201 <br /> 1,y <br />