Laserfiche WebLink
r'r <br /> _ Will'9 "P ocee hili Stied properlyGampteea. oO <br /> Applicat 5 .�..,G •- (y/,f,,�/ <br /> vD PLICATI'ON <br /> FOR OFFICE USE: s <br /> _ (For <br /> gqN��o11n-II r -ri rattle, Revocable, Suspendable) PUMP&WELL <br /> FEB 2 OEN'WRONMENTAL HEALTH,PERMIT <br /> it WATER QUALITY lication is <br /> (COMPLETE IN TRIPLICATE) N �C �1� I vL <br /> �rlctfor a permit to construct and/or install the work herein described.This app <br /> Application is herebymadetotheSar� } , <br /> in compliance with San Joaquin -g"Ordinance 'o.1862 and the rules and regulations of the San Joaquin Local Health District. <br /> made p �. IM�� <br /> Exact Site Address it '°� 9 6 <br /> Phone �i <br /> Owner's Name H� City <br /> Address <br /> II� ' License# Business Phone <br /> Contractor's Name Emergency Phone d <br /> Contractor's Address ;r No <br />` Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes 1:1 _S) <br /> TYPE OF WORK (CHECK)'. NEW WELL❑ DE EN ❑ RECONDITION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 11 OTHER ❑ PUMP INSTALLATION ID PUMP REPAIR❑ <br /> REPLACEMENT El I, Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Other <br /> page Pit <br /> Sewage Disposal Field IN Cesspool/See <br /> Private Domestic Well Public Domestic Well <br /> Property Line � <br /> .� =TYPE OF WELL _ <br /> INTENDED USE ,i. Dia. of Well Excavation <br /> ❑/NVDUSTRIAL ❑ CABLE TOOL <br /> ii El ❑ DRILLED �� Dia. of Weil Casing <br /> DOMESTIC/PRIVATE ❑ DRIVEN Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ IRRIGATION ❑ ROTARY Type of Grout <br /> 11 CATHODIC PROTECTION Other Information <br /> ❑ DISPOSAL OTHER <br /> ❑ GEOPHYSICAL � surface Seal Installed By: <br /> Contractor <br /> 11, <br /> PUMP INSTALLATION: H.P. <br /> Type of Pump., <br /> ❑ Mate Worki�Done <br /> PUMP REPLACEMENT: d <br /> PUMP REPAIR: State Work Doner��� <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state flaws, and rules and regulati'ns of the San Joaquin Local Health District. <br /> rtifies the following:"I certify that in the performance of the work for which this permit <br /> Home owner or licensed agent's signature ce <br /> is issued, l shall not employ any person in s ch manner as to become subject to workman's compensation laws of California." <br /> I Contractor's hiring or sub-contracting signature certifies the following:"1 certify that m the performance of the work forwhich this <br /> permit is issued, l shall employ persons subject to workman's compensation laws of California." <br /> i 1. R <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Date. <br /> Signed <br /> Signed X (Draw Plot_Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> I Ii <br /> PHASE 1 Date � 1 <br /> Application Accepted By �M <br /> Additional Comments: h e I Final Inspection <br /> Phase Ii Grout inspection Date <br /> Date �I inspection By <br /> Inspection By i� <br /> � � January 1 &Received By January 31 ❑ Juty 1 &Received By July 31 <br /> _ fee Is Due:'❑ ANNUALLY ❑ PER UNIT .❑ PER SITE ❑ EACH REMIT <br /> 1. BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION'S DATE DATE REMITTED AMOUNT <br /> IM 0 <br /> • FEE <br /> LESS <br /> PRORATION li <br /> PLUS I <br /> PENALTY II <br /> OTHER <br /> OTHER <br /> _3 - Delivered <br /> ' ReceiptiNa. Permit No. <br /> Is uance to Maftd <br /> n Rec'i',ed,by � � Data p 1601 E.HAZELTON AVE.,P.O.Boa 2099 �STOCKTON,CA 85201 <br /> 5..� �..,�• ':.. <br /> APPLICANT.-RETURN-ALL COPIES TO: °'- ENYIRO•NMENTAL HEALTH HSP IT/SERVICES <br />