Laserfiche WebLink
Applications Will Be Processed When Submltteeilropeny <br /> C FOR OFFICE USE: APPLICATION My J X980 <br /> (For Non-Transferable Revocable,Suspendable) P&WELL <br /> ENVIRONMENTAL HEALTH PERRAgN 30AQUIN L IcTEIAY <br /> (COMPLETE IN TRIPLICATE) FtL()&O -� `} G [3`�"I <br /> WATER QUALITY HEALTI �1S2 3 q <br /> Application is hereby made to the San Joaquin Local Heath District for a permit to construct and/orinstallthe work herein described.This application is <br /> made in compliance with San Joaquin County OrdinanceNo.1862 and the rules and regulations of the SanJoaquin Tr�C�Local Health District. <br /> City/Town <br /> Exact Site Address a y t: �C�� ' <br /> Owner Name john Brazil* Jr'. ` 3 Phone 1029 Varsity CtCity �MOUrit3�ri View . Cc3 r <br /> Address <br /> . <br /> Contractor's Name Western Well Drilling CO.License# 251$2 Business Phone 295-4332 . �- <br /> Contractor's Address B Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X <br /> No <br /> y TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION 11 WELL ABANDONMENT C1 OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Other <br /> Sewage Disposal Field Cesspool/Seepage Pit <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> r ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Weil Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing (� <br /> ❑ IRRIGATION XX GRAVEL PACK Depth of Grout Seal C� <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER ;Other Information <br /> 13 GEOPHYSICAL Surface Seal Installed By: m <br /> PUMP INSTALLATION: Contractor H P Q <br /> Type of Pum .; <br /> PUMP REPLACEMENT: <br /> C1 State Work Done <br /> 11 State Work Done C' N <br /> PUMP REPAIR: - <br /> Approximate Depth 1, <br /> DESTRUCTION OF WELL: Well Diameter _Cl <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 y <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 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 sign. uIre ertifies the following:"I certify that in'the performance of the work for which this <br /> permit is issued, I shall employ persons su ct o workman's compensation laws of California." <br /> ill or ut inspection prior to grow 'ng and a final insp on. <br /> Date: <br /> Signed Title: _ <br /> (Dr w P)ot Plan on Reverse Side) <br /> FOR DEPARTME USE ONLY <br /> FPHASE I 7 Date <br /> Application Accepted 8y <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase I incl Inspection <br /> Inspection By <br /> Date Inspection By y� Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑.PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July i &Receiv REMITBy uly 31 <br /> BASE EXPLANATION ATE <br /> REMJTTANCE $ AMOUNT DUE CHECKED <br /> ATE DATE REMITTED AMOUNT <br /> FEE — <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER j� ^' <br /> [J U <br /> Issuance Dale Mailed Delivered <br /> Received by <br /> p to Receipt No. Permit o. <br /> 1801 E.HAZELTON AVE.,P.O.BOY 2009 STOCKTON,CA 9520 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br />