81-163 - Laserfiche WebLink

Home Browse Search

Applications Will Be Processed When Submitted Properly Completed. Be Sure Togn The Application. FOR 'BICE USE: APPLICATION ` (For Non-Transferable, Revocable, Suspendable) PUMP&WELL /)d Tu— ENVIR70NMENTAL HEALTH PERMIT 1 (COMPLETE IN TRIPLICATE) WATER QUALITY 1 Application is hereby made to the San Joaquin Local Health District for 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 220�Budiselieh city/Town Stickton Owner's Name PPtar Cr. TtSOUVaB re t extern Real Est { ) 823-ti96 Address441 [bra' Street - 4(3 i .,Gen. Contractor city 1Vlanteca Contractor's Name Clar Well & Equipm;ant- License#-M.560 Business Phone -�462- 7 Contractor's Address .0 - i 4PV". Emergency Phone Is Certificate of Workman's Compensation I urance on File With SJLHD? Yes No r TYPE OF WORK (CHECK): NEW WEL DEEPEN 11RECONDITION❑ DESTRUCTION❑ " WELL CHLORINATION ❑ WELL A AN ONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank 10 0 11 Sewer Lines Pit Privy Sewage Disposal Field 100' Cesspool/Seepage Pit Other Property Line 17 Private Domestic Well Public Domestic Well 1 ' INTENDED USE TYPE OF WELL 1:10 g INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation lr :P DOMESTIC/PRIVATE 11DRILLED Dia. of Well Casing 6, 5/8" 1 ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑°IRRIGATION -ie _❑ GRAVEL PACK Depth of Grout Sea[ 50 r 3 I -❑ CATHODIC PROTECTION'-t- , R ROTARY R�- . Type of Grout ❑ DISPOSAL ❑ OTHER - Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: N a�,Gontractor' ► O 1 A.- Type of Pumps i i� H.P. PUMP REPLACEMENT: ❑State Work Dolle _ PUMP REPAIR: m ❑ State;Work Ddne DESTRUCTION OF WELL: Well Diameter '' Approximate Depth 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 note any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring r sub-coni 1 ature certifies the following:"I certify that in the performance of the work forwhich this permit is issu d, I al empl on subi t to workman's compensation laws of California."i t I III OU p on ri ting and a final inspection. Signed X Tiile:V - ' ZDate:F"Ma`_rch_ 2.001 981 (Draw Plot Plan on Reverse Side) s FOR DEPARTMENT'USEFONLY PHASEI ( I Application Accepted By ' Date `moi f� f Additional Comments: s` '-!- Phas III incl Ins P ection ' I out inspection � p� _ Inspection By P a Date I --.- Inspection By Date 3'3"+�� Fee Is Due: ❑ ANNUALLY � ❑ PER UNIT ❑ PER SITE ❑ EACH' ' ❑ January-1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT ° FEE i LESS PRORATION PLUS PENALTY + 1 i OTHER 1 f OTHER 7 I SRe'ceived by I } Date Receipt No. Permit No. Issuance Date Mailed _ Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201