Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
plications Will Be Processed When Submitted Properly Completed. r gfA— <br /> A l40% <br /> APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) JUN 23 198 <br /> MP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY SAN '0—�QLIIN 1-C1CAL <br /> (COMPLETE IN TRIPLICATE) HEALTH Di^ [ •��-- T <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work here iki�fibed.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 0�+< VA.\4. W Q%-t O `c dyh. II{ e-3 IN4- &&tr,. 44 City/Town LO fJ ( See kPaPff-sz, <br /> Owner's Name at ILS (Z (?I !y CL ixS-,n C Phone <br /> Address I� a 1 Q-1 x SO City gel Lc .hs R'1 � r G-.4 ¢-?9 0 7— <br /> Contractor's Name '41' V3 io,. CVu ptt�vtt o C O License# g(f3 1 Z.. Business Phone 3 6 G/—f V? <br /> Contractor's Address %I STIA, 4Uf CC A Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No Cy <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ j <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ (f5 <br /> REPLACEMENT❑ r <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION, ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 511.J J A� f LL %J "Ae!os= AO <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <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 <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 signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to outing and a final inspection. <br /> Signed X Title: d /CP �g� Date: 6 l ` �ko <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By ^*`^ Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By IP-- Date �— <br /> Fee Is Due: 11ANNUALLY C1PER UNIT 11PER SITE 11EACH ElJanuary 1 &R ed By January 31 El July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE +45 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 6PI;�s 6�2 <br /> Received by I Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />