80-461 - Laserfiche WebLink

Home Browse Search

Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ' FOR OFFICE USE: _ A- APPLICATION Ir (For Non-Transferable, Revocable, Suspendable) ENVIRONMENTAL HEALTH PERMIT PUMP&WELL too/ (COMPLETE IN TRIPLICATE) WATER QUALITY 6 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 Co my Ordinance No. 86f7 and the rules and regulations of the San Joaq in Lo al ealth District. Exact Site Address JAA _ � 2,3 _? 11 City/Town Owner's N me - P [ Phone 9 ea Address a City Contractor's Name Licenses/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 DEEPEN ❑ RECONDITION❑ _DESTRUCTION❑ 00 _ WELL CHLORINATION ❑ WELL,ABANDONMENT ❑ OTHER ❑ PUMP'NSTALLATIONW t PUMP REPAIR❑ REPLACEMENT© z_ .�. } DISTANCE TO NEAREST: Septic TankSewer Lines Pit Privy _ Sewage Disposal Field Cesspool/Seepage Pit Other Property Line-45_0 -._. Private Domestic Well Public Domestic Well INTENDED USE TYPE-OF WELL r F. ❑ INDUSTRIAL ,CABLE TOOL Dia. of Well Excavation 52�DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 75 " -.... ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing /Q_ _ ❑ IRRIGATION ❑ GRAVEC PACK _ Depth of Grout Seals t� r ❑ F ROTAYCType of Grout _ s.: ❑ DISPOSAL 11OTHER Other Information 0 GEOPHYSICAL Surface 5eal°Installed By: t PUMP INSTALLATION: Contractor G Type of Pump t H.P. PUMP REPLACEMENT: © state Work Done PUMP REPAIR: ❑ State Work Done I ) �+ DESTRUCTION OF WELL: Well Diameter - Approximate Depth � r Describe Material and Procedure X. 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:21 certify that in the performance of the work for which this permit A is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." e 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•shali employ-persons-subject to workman's compensationrlaws-of`California,,.'"• I wil! call or a Grout In prior io_grouting aPd a final inspecfDtf� Signed X � `Title: 'Date: t (Draw Plot Plan on Reverse Side) r FOR DEPARTMENT USE ONLY PHASE I Application Accepted By�-2� - Date Additional Comments: Pha a II Grout Inspection yPha III Final Inspection r Inspection By r Dat� ''� C� Inspection ByeDalp "12 ' Fee IS Dile: El ANNUALLY ❑ PER NIT ❑ PER SITE El EACH 13n Jauary 1 &Received By J n ary 31 ❑.July 1 &Received By July 31 ' - BASE EXPLANATION BILLING REMITTANCE';_ $ REMIT DATE DATE e r_ REMITTED _AMOUNT DUE CHECKED AMOUNT FEE LESS PRORATION # PLUS PENALTY OTHER OTHER Q^� o Received by +M Date Receipt No. Permit No, -Is anc Date '- Mailed Delivered r APPLICANT—RETURN ALL COPIES TO: ENWRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bo=2009 STOCKTON,CA 95201 :