80-799 - Laserfiche WebLink

Home Browse Search

i ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION e� (For Non-Transferable, Revocable, Suspendah e�}� 'P C f }� { `' �' tJ PUMP LL � k , ' ENVIRONMENTAL HEALTH FERMI �- (COMPLETE IN TRIPLICATE) WATEiA QUALITY SEP 16 1980 Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work hereindesciiri``b��ed.This application is may made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of tAAH WAi Hh, f fristrict. Y K Exact Site Address 1.4513 E. Sar ent Road City/TownHFA TL H DiSTRI r- Owner's Name Wm. H. Carter Phone Address --14513 E. S etzt Rd city Lodi Ca. Contractor's Name GoehrincT PU16P License f# 309031 Business Phone 727-5548 Contractor's AddressP.0.BOX 1.13 { LoCkefOrd Emergency Phone Is Certificate of Workman's Compensation jInsurance on File With SJLHD? Yes XX No TYPE OF WORK (CHECK): NEW WELLr❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ .f WELL CHLORINATION 11 WELL ABANDONMENT 13 OTHER 11 PUMP INSTALLATION IJ PUMP PUMP REPAI 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 i ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ,. ❑ DOMESTIC/PRIVATE ❑ DRILLED--W— 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 ti Type of Pump H P PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: )gState Work Done _ made repairs on used 15HP x7tetp �1i�l}�i __ p pi 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 j} I ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Homeowner 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 hirin sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this '}r per issued, all employ persons subject to workman's compensation laws of California." }I I it 11 for ut pection prior to grouting and a final Inspectio A Signed X A Title: Date: (Draw Plot Plan on Rev rse Si e) —FOR DEPARTMENT USE ONLY-- — y PHASE I G� 1 Application Accepted By Date a" Additional Comments: Phase II Grout Inspection P Ill Final spection r Inspection By ' Iin Date Inspection By Date f U Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 BILLING REMITTANCE $ REMIT - BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS r PRORATION PLUS i E PENALTY OTHER OTHER F Received by Date 1 Receipt Na Permit o. - fss once Date Mailed Y 1 _ Delivered .rte APPLICANT—RETURN ALL COP4E5 TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE., Box 2009 STOCKTON,CA 95201 .