82-150 - Laserfiche WebLink

Home Browse Search

Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application, FOR OFFICE USE: I� APPLICATION (For Non-Transferable, Revocable, Suspendable) PUMP&WELL I ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) II 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. r Exact Site Address 5525 S. Stariley Rd City/Town Stockton Owner's Name W.D. "Bud" Reynolds Phone 465^4228 Address 6294 S. Stanley Rd city Stockton _ Contractor's Name Clark Well &' Equipment License# 371560Business Phone 462-5597 Contractor's Address 2024 E. Charter Wary Emergency Phone NA Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL❑ DEEPENil RECONDITION❑ DESTRUCTION❑ 6' WELL CHLORINATION ❑ WELL ABIANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ r REPLACEMENT❑ existing W@1 II DISTANCE TO NEAREST: Septic ani ewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE li TYPE OF WELL ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation all drilled 1920 ® DOMESTIC/PRIVATE I❑ DRILLED Dia. of Well Casing 8" ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal install " ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout _ na t0 top � ❑ DISPOSAL ❑ OTHER Other Information v ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H.P. I PUMP REPLACEMENT: i❑ State Work Done PUMP REPAIR: I❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth ',Describe Material and Procedure i k 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. t Home owner or licensed agent's signature certifies the fallowing:"I certify that in the performance of the work for which this permit is issued, I shall not p o y person in such manner as to become subject to workman's compensation laws of California." Contr cto hirin s -cont csignet a certifies the following:"I certify that in the performance of the work for which this per ' is sue s all p rs ns subt to workman's compensation laws of California." I i I r ut I s do pr' t ut ng and a final inspection. Signed X Title: U-Clark Well Date: April 29.1982 (Draw Plot Plan on Reverse Side) ` FOR DEPARTMENT USE ONLY PRASE I Application Accepted By Date L Additional Comments: Phase II Grout Inspection rP,hase Ill Final Inspection Inspection By Date Inspection By._—/'` Date -5- Fee Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 I BILLING REMITTANCE $ REMIT BASE ',EXPLANATION PATE DATE REMITTED AMOUNT DUE CHECKED ! AMOUNT FEE LESS PRORATION I PLUS PENALTY 1 OTHER i OTHER �. � �w Received by Date Receipt No. Permit No. Issue ce flat Mailed Delivered - f ?/ l APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AYE.,P.O.Bax 2009 STOCKTON,GA 95201