81-475 - Laserfiche WebLink

Home Browse Search

'""` 1Applications Will Be Processed When Submitted ProperlyCompleted de sure Ioalgn Ines�pprrcauwr. FOR 011 ICE USE: APPLICATION (For Non-Tran)Sterable, Revocable,Suspendable) PUMP&WELL G ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is . made in compliance with San Joaquin County Ordinance No.1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address 1nrat10_nS--S.ee a- City/Town Owner's Name Amoco Minerals Company Phone - 761-5921 Address 333 W Hampden to 500 City 01421 Contractor's Name Reid Drilling Company License # Business Phone - 265-2307- Contractor's Address P.0-BOX 1546LGdspera WY 82602_ Emergency Phone CAMP Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No _XX TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHERM PUMP INSTALLATION ❑ PUMP REPAIR C1 REPLACEMENT❑ exploratory hale to be abandoned Uponc mpl eti on J DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit P vy Sewage Disposal Field Cesspool/Seepage Pit Other N/A Property Line Private Domestic Well Public omestic Well INTENDED USE TYPE OF WELL nrnx F i rh ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well E avation_� ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well acing nnnim ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of asing ❑ IRRIGATION ❑ GRAVEL PACK Depth of rout Seal none ❑ CATHODIC PROTECTION XXW ROTARY Type o Grout ❑ DISPOSAL ❑ OTHER Othe,lnformationtert hole to he oa,ban p Iran X)M GEOPHYSICAL Su ace Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter. 6 1 nG Approximate Depth Describe Material and Procedure-neat cement at base. fresh wat�r. heavy mild to 50 ft below surface; cement cap 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. Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." 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." will c@11 for a Gro nspec ion prior to grouting and a final inspection. Nl`f p 6l,5frr",t jwc, 4- Signed Signed X [ Title: Pro ieGt f enl nOi st _ Date: Z3 lwie 1 AR1 0. A. Kaufman (Draw Plot Plan on Reverse Side) FOR DEPA TMENT USE ONLY PHAS Date Application Accepted BY Additional Comments: Phase II Grout Inspection hase III Final Inspection Inspection By Date Inspection R. . Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EA H ❑ Ja uary 1 4 R'e ived By January 31 ❑ July 1 &Received By July 31 REMIT BASE EXPLANATION BILLING` 1 ANCE S AMOUNT DUE CHECKED DATE" TE REMITTED AMOUNT _ c FEE k. LESS PRORATION 1= PLUS PENALTY OTHER OTHER Received by Date Receipt No. "°'Permit-No.- - Issuance Date Mailed 0ellveretl APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201