83-52 - Laserfiche WebLink

Home Browse Search

Applications Will Be Processed When Submitted Properly Completed. Be SureTo.SI n-Tf> iA tion. T�n to ✓e Dare I r FOR OFFICE USE: APPLICATIONS d Scomp�eT;cn �j�,��! t ?. (For Non-Transferable, Revocable, 1spendabl3 . '� MP 8,WELL- ..� ENVIRONMENTAL HEALTH PEMI �10 COMPLETE IN TRIPLICATE);7i QUALITY4;ZP 750, Application is hereby made to the San Joaquin LocaPHealth District fora permit to construct and/or install the,% �h r 1 IMperibed.This application is made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulai�wnbt lof-the San Jo Lii k gcal Health District. I Exa t Site Address 0" Q�'L- re, 2rJ�Aso_ �i �w/fovv t �Oj cc !'9r#'�51_rloo' I�ts1RN�ss t Owner's Name r. Q sc a V PhA - 4O W �l` City x Address n� �f: Cit Contractor's Name Purviance Drillers Drilling License# 3 11 9.Z3 Business Phone Contractor's Address Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL[1DEEPEN ❑ RECONDITION 11DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ `PUMP INSTALLATION ❑ PUMP REPAIR•® REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank T Sewer tines 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 ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing . 2C IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout. ��k ❑ DISPOSAL ❑ OTHER Other Information G ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Purviance Drillers Drilling Corp. Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done ' PUMP REPAIR: i/ ER state Work Done _ elhaelcli _ DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure r 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:1 certify that in theperformance of the work forwhich this permit is issued, 1 shall not employ any person in such manner as to become subject to-workman's compensation laws of California." Contractor's hiring orsub-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." C I call for Gr u spection prior to grouting and a final^inspection. -11 �- Signed X - � Title:� Vit — OY"e$Igo f Date: 13-83 _ (Draw Plot Plan on Reverse Side) t FOR DEPARTMENT USE ONLY PHASE I J f ' Application Accepted By G Date Additional Comments: Phase 11 Grout Inspection Ph a III Final Inspection ' Inspection By Date Inspection By lDale j +1111 Fee IS Due: E3ANNUALLY 11PER UNIT ❑ PER SITE C1EACH' ElJanuary 1 &Received 13y Januar 31, ❑ July 1 &Received By July 31 a I T} BILLING REMITTANCE, $ REMIT y BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS ] 'F PRORATION ti PLUS PENALTY ' a OTHER OTHER i Received by Date Receipt No. Permit No llssuane Date Mailed Delivered i APPLICANT=RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PER 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201