Laserfiche WebLink
Applications Will Be Processed When SubmittedProperly Gompleiea. tsesure 155!?1 8nexn1M.,Wrr. <br /> FOR OFFICE USE: APPLICATION U <br /> (For Non-Transferable, Revocable,Suspendab191AN JOA U I NI <br /> •� � ftQM&wl:tt <br /> ► ENVIRONMENTAL HEALTH PERMIT HEALTH DISTRICT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> 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 <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San JJo&,,,in Local Health District. <br /> Exact Site Address 1 31 • Paradise City/Town V <br /> Owner's Name Reclaim island Lands Co. Phone <br /> Address 301 W, Stewart City Lathrop <br /> Contractor's Name V Alff C� icense#Z, 6CI42 Business Phone <br /> Contractor's Address 1165 Main S f P. 0. Box 746 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ `hgdl <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE . ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL � !! Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor .44 Z <br /> Type of Pump H.P.. Vl <br /> PUMP REPLACEMENT: LR"State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will c II for Gro spection prior 10 grouting and a final inspe <br /> Signed X �7 a__s� f Title: Date: <br /> (Draw Plot Plan on Rev se Sidef <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date 4p <br /> Additional Comments: <br /> Phase 11 Grout Inspection P 11 Fin ns <br /> Inspection By Date Inspection B <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 July 1 &Received By July 31 <br /> REMIT <br /> EXPLANATION BILLING REMITTANCE OUNT DUE CHECKED <br /> BASE <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> lo �— <br /> !- Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISEHVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />