79-1041 - Laserfiche WebLink

Home Browse Search

Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable,Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY 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 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 460 SCHUITE RD. City/Town Owner's Name CHARLES TOLLEY Phone 836-2336 Address 460 SCHULTE RD. City TRACY Contractor's Name FREITAS ELECTRIC License#338471 Business Phone 835-2814 Contractor's Address 5362 W. "G" ST• Emergency Phone S/A � Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes Y No TYPE OF WORK(CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR k 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 A I� DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal C ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout C ❑ DISPOSAL j ❑ OTHER Other Information I ❑ GEOPHYSICAL Surface Seal Installed By: + PUMP INSTALLATION: Contractor FREITAS ELECTRIC f ---� Type of Pump SUBMMSIBLE H.P, 1 I f PUMP REPLACEMENT: ❑ State Work Done I PUMP REPAIR: El } State Work 11e DESTRUCTION OF WELL: Well Diameter y w.a w Approximate Depth ' Describe"Material and Procedure I hereby certify that Ihave 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 hiring or suh contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shalt employ persons subject to workman's compensation laws of California." all 1 Grout Inspe tion prior to grouting and a final inspection. ' Signe Title: �lg-�-cn- � _ ____ Date: I (Draw Plot Plan on Reverse Side) I i F RDE ARUSE ONLY TME WI -7 PHASEIApplication Accepted By Date Additional Comments: Ll Phase Ift Grout Inspection Phase III Final Inspectio Inspection By I Date Inspection By C -79i Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BILUNG REMITTANCE $ BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED t ;AMOUNT FEE !!! LESS PRORATION PLUS j PENALTY ! OTHER OTHER 4 —7 ko ci "7 q— —I/I Received by Date Receipt No, Permit No. - Issuance Date Mailed Delivered 4 r APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201.