82-518 - Laserfiche WebLink

Home Browse Search

Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE U;E: IAPPLICATION Ror Non-Transferable,Revocable, Suspendable) PUMP&WELL vu G ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) ' JF/4iy %� WATER QUALITY 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 County Ordinance No. 1862 and the rules and regulations of the San�Joaquin Local Health District. Exact Site Address b SEG �Tk Ot, A�� City/Town 1 AA1-PE C A Owner's Name SAoJ .�bf iUteJ C'�U Tom, Phone 944- 3330 Address 'L22 t City s"[t)C- -'000J Q Contractor's Name e Q>J i:a 56S Vy-S License# Z-f c Y) 3 Business Phone `_'�4'S - H 1 1 S ) Contractor's Address 3S"?-s- Pe-L.A:,3 bA L G; MO DL-S'1 o Emergency Phone Is Certificate of Workman's Compensation In rance on File With SJLHD? Yes X No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION ^� WELL CHLORINATION Id WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ lam' REPLACEMENT❑ ^� 1 r DISTANCE TO NEAREST: Septic Tank L- O Sewer Lines 2-910 Pit Privy Sewage Disposal Field_. o© 'f Cesspool/Seepage Pit Other 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 31161, 74, 71--- •IRRIGATION GRAVEL PACK Depth of Grout Seal j201' ❑ CATHODIC PROTECTION ROTARY Type of Grout LicMt,�-7" Al ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL CAiaJrOr 'p Surface Seal Installed By: PUMP INSTALLATION: Contractor Fla w Ef. LQ 61-L "+tr AC gQ-.SP1 P L',4t, Ajcz � Type of Pump S U 13/nA;�1/34-4E H.P. 3 O PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure 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:"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 for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." ill call for a Grout Ins ction rior to grouting and a final inspection. � Signed Xn CC Title. --d " '� �' Date: (Draw Plot Plan on Reverse Side FOR DEPARTMENT USE ONLY PHASE I 12> Application Accepted By - Date Additional Comments: ^r 1 P Lase II farout Inspection (RPh se III FinalrI spection Inspection By mate Lo—Fa- Inspection By D r010 1 'gZ- Ver- Fee Is Due: ❑ ANNUALLY ❑ PER UNIT El PER SITE 11 EACH ❑ January 1 &Received B January 31 my 1 &Receivedi° } REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER 163 y Q -y 2 Received by Date Receipt No. Permit No. Is uance to Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201