80-64 - Laserfiche WebLink

Home Browse Search

A tions WI11 Be ProcessedW rt ubmitted Properly Completed. Be Sure To Sign The Application. FOR-OFFICE USE:' FEB J �9$� APPLICATION c.c� r Non-Transferable, Revocable,Suspendable} w1 r (� SAN J ^.QUI", t."T LRONMENTAL HEALTH PERMIT PUMP&WELL ` (COMPLETE IN TRIPLICATE)HEALTH DISTRICT . WATER QUALITY Application is hereby made to the San Joaquin Local Health District for a 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 6398 E. PINE ST City/Town LODI CA RAMER 0. PFEIFFLE 368-1453 Owner's Name Phone Address 63'98 F.. PINE ST City LODI , CA 952,40 Contractor's Name --SAN JOAQU IN PUMP CO. License# 381012 Business Phone 369-8471 Contractor's Address $69 E_. ME ST. , LODI, CA Emergency Phone 369-8471 Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes XX No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ICK PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field 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 ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout © DISPOSAL ❑ OTHER Other Information © GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor SAN JOAQUIN PUMP CO. �. Type of Pump DOMESJIC .SUBMERSIBLE _ H.P. 1-1/2 HP W PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done 'DESTRUCTION OF WELL: Well Diameter k Approximate Depthil Describe Material and Procedure f ~ r 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 forwhich this permit is issued, I shall employ p sons subject to workman's compensation laws of California." I will♦,ca r ut n ecti pr'or to routing and a final inspection. Signed X 1 Title: OFFICE—MGR,_SAN JOAQUIN PUMPDate: 1-28-80 (Draw Plot Plan on Reverse Side) FORIEPAR MENT USE ONLY PHASE I Application Accepted By Date Additional Comments- Phase ommentsPhase 11 Grout Inspeclion T Ph Final ins ction Inspection By Date �� InslSpection By G`� ate Fee Is Due: El ANNUALLY El PER UNkT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Juky 31 BILLING REMITTANCE $ REMIT BASE EXPLANATION DATE DATE' REMITTED AMOUNT DUE CHECKED AMOUNT FEE Cts (— LESS PRORATION ' PLUS PENALTY OTHER OTHER Received by 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