80-864 - Laserfiche WebLink

Home Browse Search

Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USF: APPLICATION (For Non-Transferable, Revocable, Suspendable) PUMP&WELL ' ENVIRONMENTAL HEALTH PERMIT u }' (COMPLETE IN TRIPLICATE) WATER QUALITY �1 Application is hereby madeto the San Joaquin Local Health Districtfora permitto 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. j Exact Site Address Fabian Rd .-1 mi. west of Corral H0 11ow Ridi#,y*TDwn nor-th side Owner's Name Charles Geer Phone 835_1083 Address w 23866 S. Berg RC1., City Tracy Oa Contractor's Name Heermings Broa, License#_29-0-813— Business Phone___54 _-_J_t85 0 Contrac®or"'s Address,,525 Pelandal a;Modesto Emergency Phone _ , � 1 `��. Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_ � No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ i DISTANCE TO NEAREST: Septic Tank 62 Sewer Lines Pit Privy Sewage Disposal Field 2{ Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE-GF WELL- ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 1 lit �i DOMESTIC/PRIVATE 1:1 DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing {�� ❑ IRRIGATION IX GRAVEL PACK Depth of Grout Seale. t 13CATHODIC PROTECTION ROTARY Type of Grout 'Bentonite 1 ❑ DISPOSAL ❑ OTHER Other Information -"`tel_ab— byems` t ❑ GEOPHYSICAL Surface Seal InstalledBy, driller T PUMP INSTALLATION: Contractor } Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done j PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth _ 95 Describe Material and Procedure _ r I hereby certify that I have prepared this application and that ttyof-work will be done in accordance with San Joaquin County ' ordinances, state laws, and rules and regulations`of`the-San Joaquin Local Health District. j Home owner or licensed agent's signature certifies the following:"1 certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to bee4me 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 , s permit is issued, I shall employ persons subject to workman's compensation laws of California." I will call for a Grout Inspection prior to grouting and final inspection. - Signed X Hennings Bros, by y / Sec* Date: 10-13-8o —_Z (Draw Plot Plan on Reverse Ide) FOR DEPARTMENT SE ONLY PHASE Application Accepted By On Datetd- N-26 Additional Comments:_Fhj ase II Gro ut�jlspection a fll final_Jgspection Inspection By Inspection By ate Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By JUly.3 1 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED _ DATE DATE REMITTED -AMOUNT FEE y 3 LESS PRORATION PLUS PENALTY OTHER 1 OTHER Received by Dat4 Receipt No. Permit No,.__ T'IssuaFee Date Mailed Delivered - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES "1601 E.HAZEL-TON AVE.,P.O.Box 2009 STOCKTON,-C j952