79-1169 - Laserfiche WebLink

Home Browse Search

— rte t3 v jlll �l Applications Will Be Processed WhenuAPPLICA,TIONR - FOR (]FFICE USE: _ (For Non-Transferable, Revocable, S daVbT 151979 PUMP&WELL ENVIRONMENTAL HEALTH PERMIT IJ WATER QUALITY SAN JOAQUIN LOCAL (COMPLETE IN TRIPLICATE) Q�$-fRl@-Pescribed.This application is.� Application is hereby made to the San Joaquin Local HealthDistrictforapermittoconstructandbrl3��'Ie trict. made in compliance with oaq i ounty�rdina ce N . 18 2 a the rules and regulatiCI�yJ�ghe San a in LT i Exact Site Address wn 1/j n I / X19 P- fi' �el�/rs 911 J Phone Owner's Name City 51 G Address L /�'l cense# a 8usin s ho Contractor's Name Emergency Phone , V1J= l Contractor's Address No Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes TYPE OF WORK (CHECK): NEW WELL LW DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ r WELL CHLORINATION ❑ WELL ABANDONMENT 11 OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR REPLACEMENT❑ fi Pit Privy �6 7 Sewer Lines k DISTANCE TO NEAREST: Septic Tank Cess ool/S epage Pit Other Sewage Dispos��i�ld p // '4' Public Domestic Well OI property Line Private Domestic We11 1, INTENDED USE TYPE-OF-WELL 11 CABLE TOOL Dia. of Well Excavation I ❑ INDUSTRIAL Dia. of Well Casing ®-'DOMESTIC/PRIVATE 13 DRILLED ' ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing WOO ❑ IRRIGATION ❑�-.,r LLGRAVEL PACK Depth of Grout Seal Lwf�OTARY Type of Grout f ❑ CATHODIC PROTECTION Other Information ❑ DISPOSAL 13 OTHER f� Surface Seat Installed ❑ GEOPHYSICAL PUMP INSTALLATION: Contractor-'j`—�� Type of Pump rJ yI/J� DH.P. 1 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." I Contractor's orsub-contracting signature certifies the following:"k certify that in the performance of the work for which this perm' s ' d, I shall a persons subject to workman's compens laws of California." t I III r out Insp ctio prior to grouting and a final inspecti / l� r Title: Date: Signed X - -- -.. (Draw Plot Plan on Reverse Side) - '* T USE ONLY � r PHASE i Date lJ 79 Application Accepte By i Additional Comment . Phase Phase HI Final Inspection i Date 4 - Inspection By Date Inspection By July 1 &Receiv July 31 Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ REMIT i. BILLING REMITTANCE $ AMOUNT DUE CHECKED BASE EXPLANATION DATE DATE REMITTED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER —7 Receipt Na. Permit No. Issuance Date Mailed Delivered ..-r Received by Date CA 95201 1601 E.HAZELTON AYE.,P.O.Box 2009 � STOCKTON; APPLICANT—RETURN.ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES �. -