80-686 - Laserfiche WebLink

Home Browse Search

Applications Will Be Processed When Submitted Properly Complet re�oZSfgribrhVApWic�ilo}I� FO�Of'i4CE USE: APPLICATION(For r1h'��I +. (For Non-Transferable, Revocable,Sus ble)A a I G 4 19SU PUMP&WELL ' - ENVIRONMENTAL HEALTH PERMIT QUALITY UALITY SAN ,�OAQ'UIN LOCAL (COMPLETE IN TRIPLICATE} _ Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or i�hS�Ht TUh rMr�iYiE scribed.This application is E� made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. r Exa,t Site Address(�. �� r e ll,2� �, '-W City/Townc��c�C 6SET C B. Q Owner's Name -4w- r` Phone �D 19 J.21-6 Address Z- mn'. e _City Contractor's Name 3 4 � �� J License <,.:Uusiness Phone "7 f Contractor's Addres/'.Z 5�it.,...�_T14 f t. R_ipa j5L� Emergency Phone !!71V,6'-4e '3 se 77' t Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL91--_ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION a'PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank, Sewer Lines Pit Privy ; Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ' ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation P-1SOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing - - ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION 'r 8-ROTARY Type of Grout I? 15�- -_6;z i ❑ DISPOSAL OTHER Other Information �} 11 GEOPHYSICAL Surface Seal Installed By: i PUMP INSTALLATION: Contractor C', mss Type-of Pump 4L 12 H.P. 2 PUMP REPLACEMENT: ❑State Work Done PUMP REPAIR: ❑ State Work Done I DESTRUCTION OF WELL: Well Diameter Approximate Depth . _:- -Describe Material and Procedure i I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County j 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 for which 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." I will call for a Gr ut Inspection prior to grouting and a final inspection. Signed X Title:+ 1,��."' '� Dater r �� (Draw Plot Plan on Reverse Side) t a;- /:z7z SEONLY PHASE IApplication Accepted By c7 Date U -_� " Additional Comments: Phase II Grou I pection P e Final I ection, Inspection By� Date S � _ Inspection-8 ate Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By Januar 31 ❑ July 1 &Received By July 31 REMIT BILLING REMITTANCE $ BASE EXPLANATION DAMOUNT DUE CHECKED. ATE DATE REMITTED AMOUNT FEE LESS PRORATION _ PLUS i PENALTY OTHER NN A OTHER 's 437 Received by Date Receipt No. Permit No, Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201