81-8 - Laserfiche WebLink

Home Browse Search

Applications Will Be Processed When Submitted Properly Completed. Be S Sign The Application. O,F�FICE SE: =1v, APPLICATION (For Non-Transferable, Revocable,Suspendab ENVIRONMENTAL HEALTH PERMIT '' PUMP&WELL (COMPLETE IN TRIPLICATE) WATER QUALITY a Application is hereby made to the San Joaquin Local Health District fora permit to 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. Exact Site Address /a-SO E F-P City/Town lam/ Owner's Name J4hW 144440-65 G/AEN Phone A1444- Address fps/ E 471::J.1592A/ Fn City 40-41 "- Contractor's Name 6/&S'CW 3W&c� License# 71752 Business Phone '75-9-3-3 27 I Contractor's Address C_Z,_-A derA/7:'S Emergency Phone -a¢ Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes L-i No TYPE OF WORK (CHECK): NEW WELL$ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION)J PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank /4-0- Sewer Lines 5e _ Pit Privy — Sewage Disposal Field /�e Cesspool/Seepage Pit Other Property Line 5'0 Private Domestic Well I/!9 Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation 1.2 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing I .f ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing /® ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout 7 5ZAV-1e�— ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: 614SDa PUMP INSTALLATION: Contractor Type of Pump H.P. / PUMP REPLACEMENT: ❑ State Work Done /n PUMP REPAIR: ❑ State Work Done DESTRUCTION OF W L: ) Well Diameter Approximate Depth '+ tO Describe Material and Procedure f (� F? 1 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. Homeowner 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 wi call fora rout Inspection prior to grouting and a final inspection- Signed XTitle: CA2a �. Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE [ �� Application Accepted By Date Additional Comments: 01ase II Gr ut Inspection PharA III Fin Inspections dd/ Inspection B,N Date ® /&! Inspection By� V Date � � OI nrA Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BILLING REMITTANCE $ BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE � Oa �� LESS PRORATION PLUS PENALTY OTHER OTHER � I Received by Date Receipt No. Permit No. Ilssua6ce Date Mailed De red / APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601.E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA