Laserfiche WebLink
.WlC 1V 1IAC NF)Ik;4tIo". <br /> FOR OFFICE USE: ...APPLICATION <br /> _ (For Non-Transfereblel Revaea,ble,Suspendable) <br /> ENVIRONMENTAL H 4LTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER 40AtLITY <br /> Application is hereby made to the San Joaquin Local Health DistrictfOr,a permit to construct and/or inttell the work herein described.This application i" <br /> made in compliance with San Joaquin.9D ty Ordinance No.F62 and ilia rules and regulations of the San Jin I Health District. �+ <br /> Exact Site Address,11700 _Z _�____ City/TQwn_: T IV r"{ <br /> Owner's Name A5&oK -b&ll//.�/iI S _ �._.. _._ Phone--���a� "` .�C�18 <br /> .._... - <br /> Address <Ae"r _ City <br /> Contractor's Name 4It License M,-? r?I !!4 Business Phone/ <br /> Contractor's Address F<Oi,7 Sa4r. Aft ,�.._,._ _ EmaergallcyPhone <br /> Is Certificate of Workman's Compensation Insurance on:Flle With SJLHD7 Yes _ No <br /> -."-TYPE OF WORK (CHECK)'' "-*NEW WELL R DEEPEN RECONDITION❑ DESTRUCTION❑ <br /> '"WELL "CHLORINATION ❑ ' WELL' ABANDONMENT ❑ O-tHFR D 'PUMP INSTALLATION❑ PUMP REPAIR❑ D " <br /> REPLACEMENT-❑ Q <br /> DISTANCE TO NEAREST: Septic Tank �� ewer Lines Pit Privy <br /> Sewage Disposal Field Infer f_-- , Cesspool/Sfeepage".Pit _ Other <br /> PropertyA_jne _Private'Upmeslic Well _40 -A: Public Domestic.Well <br /> INTENDED USE x. TYPE OF:WELLm <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 Dopth of Grout Seal f <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Sul lace Seal Installed By: dXWNC= a " <br /> PUMP""INSTALLATION., Contractor <br /> Type of_ump. _ .-_ H.P. <br /> PUMP REPLACEMENT: . f. ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF!WELL: Well Diameter __ Approximate Depth <br /> -.. Describe Material and Prrx:edure <br /> I hereby certify that >:have prepared this application ami that the walk will be done in-accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the;inn Joaquin Local Health District. -- <br /> Home owner or licensed agent's signature certifies the fallowing:"1 r:eltjfy that in the performance ofthe work forwiTich this permit <br /> is issued, I shall not employ any person in such..mannet as to beoolna subject#o workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature-certtiies tha fellowingi 1-certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I 'I call f a& AIA)IC-1 <br /> ion prior 1 routing and a llnal Inspeclibn. <br /> Signed Tilte. _ Z nr�' .Date:/7 "Fl. & Zi <br /> (Draw Plot Plan on Revee Side) <br /> FO DEPARTMENT USE ONLY <br /> PI LASE I -- 1. <br /> Application Accepted.By <br /> .Additional Comments: <br /> Phase 11 Grout Inspection Phase I11 Final Inspection <br /> Inspection By Date Inspection By Date, <br /> Fee Is Due:.[]:'ANNUALLY -❑FEIR-LINIT ❑ PER SITE: t❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ 'AMOUNT DUE CHECKED <br /> DATE DATE REMITTED= AMOUNT <br /> FEE . Q/1�IelI <br /> LESS <br /> PRORATION - <br /> PLUS r ` <br /> PENALTY $� ry <br /> OTHER <br /> OTHER lP� <br /> Received'by Date Receipt No. Permit No. IssuanLVDate Mailed "'Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.Box 2009 STOCKTON.CA 95201 <br />