82-105 - Laserfiche WebLink

Home Browse Search

Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. -� FOR OFFICE USE. �~ APPLICATION r (For Non-Transferable, f;evocable,Suspendable) PUMP&WELL -,- ENVIRONMENTAL HEALTH PERMIT . .. c � p W(COMPLETE IN TRIPLICATE) l „�-TE.R.QUALITY, , 1 s i Application is hereby made to the San Joaquin Local Health District fore permit to construct and/or install the work.herein described.This application is l made in compliance with San JoaquinT�County,Ord�i-nr�lance No 1862 and therulesand regulations of the San Joaquin Local Health District. � £S��JRAnd 7H aF yNF I�NCI$ City/Town Exact SiteAddreil'W, siT)E Er'Doi Owner's Name J1q 10 lTt J`Zy;f f�- Phoned 1'9_44-8429 Address . PI i `o eD111C �+Fti,a_tin w a ;:. »x: Gity c►:°°? €"STOCKTON _ Contractor's Name �� 21;.C?1 (?,!I`� A!�f License# � "' '� � Business Phone" +`.- r • u Contractor's Address rti � 1 °�t .` '' r �i *�% ' Emergency Phone". Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK'(CHECK): NEW'WELL❑ DEEPEN ❑ RECONDITION El -bESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ry OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ t k DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy I - Sewage Disposal Field Cesspool/Seepage Pit _. ._ Other Property Line Private Domestic Well ' Public Domestic Well INTENDED USE y,. TYPE OF WELL ❑ INDUSTRIALt ❑ CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE 11DRILLED f { Dia. of Well Casing 11DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK: Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY t Type of Grout ❑ DISPOSAL ❑ OTHERS Other information �w I ❑ GEOPHYSICAL" 'Su rface.Sea 1 Installed By:w_ PUMP INSTALLATION:' Contractor �' S14ATFR SYSTEMS Type of Pump _�.��I-1-IRB-LNE __ H.P. + PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter �ECI�'� q .. T, , ... Approximate Depth �1.&1 FFFT Describe Materialand.Procedure_RENWI-Nr PUMP; PRESSURETANK• PIPING, FILLING, 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 theperformanceof the work for which this permit Y 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 forwhich this permit is issued, I shall employ persons subject to wo'rkman's compensation laws of California." Iwillc f a ; } Mut Inspecti prior to .luting n a final inspection. - SignedX I Title: _ASS l A I CR/SCYYCit JIJr I . -. __. Date. OL 1 1) D�n [ � (Dra .Plot Plan on Reverse Side) ._ GLEN L r ..SII I WZEL_L T t ' FOR DEPARTMENT USE ONLY - PHASEI f Application Accepted By ' __ _ �� ! Date�-- - Additional Comments: 'f I Phase II Grout InspectionPhase III Final Inspection n � k Inspection By Date .7' Inspection By Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH: ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31REMIT # BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED { DATE DATE E�Ot TTED AMOUNT ^� FEE LESS PRORATION X PLUS ?{ PENALTY (J ' n� r OTHER J 1 b / OTHER r 16. Receive by ate- - Receipt No.' Permit No, lesuanc6 Date Mailed Delivered' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON.CA 95201