82-165 - Laserfiche WebLink

Home Browse Search

,y Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: // APPLICATION ; A (For Non-Transferable,Aevocabie, Suspendable) PUMP&WELL I E�- ENVIRONMENTALHEALTH'PERMIT WATER QUALITY. (COMPLETE IN TRIPLICATE) I�,36..5"'iC'. t�a.¢�e�-•P�, ., . Application is herebymadetotheSanJoaquinLocalHealthDistrictforapermittoconstructandlorinstalltheworkfiereindescribed.Thisapplicationis J made in compliance with an Joaquin County Ordnance No. 1862 grid the rules and regulations of the San Joaquin Local Health District. Exact Site Address_�"d �� - i °� '� ,�`"s� City/Town Owner's Name , Phone Address r� City I Contractor's NamestO 09161 of�- 1 License#_Z937Z r Business Phone- Contractor's Address &- - Emergency Phone- - Is Certificate of Workman's Compensation insurance on File W S`LHD? Yes No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION .O WELL CHLORINATION 11 WELL ABANDONMENT ❑ OTHER 11 PUMP INSTALLATION it PUMP REPAIR❑ REPLACEMENT❑ l DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other 'o 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 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY I Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL ► Surface Seal Install By: I PUMP INSTALLATION: Contractor i Type of Pump H.P. -U CT1 PUMP REPLACEMENT: ❑ State Work Done I (� PUMp.m State Work Done 2?X24 f DESTRUCTION OF WELL: Well Diameter Approximate Depth I Describe Material and Procedure t 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. 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 forwhich this permit is issued,11-shall employ,persons,subject to workma_n's compensation laws of California." s 1 wil call for a Grout Inspection prior o gr�uting and a final nspection. ' "''" —� Signed X "'� Date (Draw Plot Plan on verse Side) FOR DEPARTMENT USE ONLY PHASE f Application Accepted By. .- - Date Additional Comments: Phase II Grout Inspection II �al �Date �Z Inspection By_ Date Inspection By Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 Cl July i &Received By July 31 REMIT I BASE TEXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE,, DATE REMITTED AMOUNT 'e FEE �+ A LESS f + PRORATION PLUS PENALTY I _ OTHER OTHER 5 Received by Date Receipt No- Permit No, I uanc Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 85201 r '