Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
i a Y s'wl Be Processed 4MUSubmitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: (F'. � a2 APPLICATION <br /> SEP 1 (For Non-Transferable, Revocable,Suspendable) i � <br /> (PUMP&WELL <br /> �At1 ,- , f S''lp'�NMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICAT WATER QUALITY <br /> Application is hereby made tothANJ aquinLocal Health Districtforapermit toconstruct and/or install the Work herein described.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 _ 11204 F Bator ]Rd- Cit /Town <br /> y Stockton <br /> Owner's Name nan Phone 931-5406Address rL` <br /> Contractor's Name ! W;Wter License# 2676 Business PhCity —. c- <br /> SySteMSone <br /> Contractor's Address 7_ 7[t _jij ��A3f 931 3210 <br /> REQ. Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ r <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR M <br /> REPLACEMENT❑ l� <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy O <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic WellPublic Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED <br /> Dia. ofa Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ <br /> DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY <br /> 11DISPOSAL Type of Grout <br /> ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor_ .nnrma,,I <br /> Type of Pump t13rbin� H P _ <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: .PV State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> p Ir <br /> Describe Material and Procedure Apro Imate Depth <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County R <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner 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 for which 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 grouting and a final inspection. �^ <br /> Signed X ` rrp - z-f -riz a ,- Title: Date: 1�- L <br /> (Draw Plot Plan on Reverse Side) <br /> PHASE I <br /> .�FOR DEPARTMENT USE ONLY <br /> �>tXhApplication Accepted By �j� /=Ll <br /> Additional Comments: Date t <br /> Phase II Grout Inspection Phas 011 Find Inspection <br /> Inspection By_ Date <br /> ✓� . y��. <br /> G----- Inspection By t�c�z -pate <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE El EACH ❑ January 1 8 Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCEREMIT <br /> $ A <br /> DATE DATE REMITTED MOUNT DUE CHECKED <br /> FEE ------cc AMOUNT <br /> LESS �v <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER ,/ <br /> ` <br /> Received by Date <br /> Receipt No. Permit No. suanc Date Mailed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES Delivered <br /> 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />