Laserfiche WebLink
ApplicationsWill BeProcessedWhen Submitted ProperlyCompleted BeSureToSign TheApplication. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) --,ATEP MLITY f <br /> Application is hereby madeto the San Joaquin Local Health Districtfora permitto construct and./or install thework herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No.1862 and the rules and regulations of the San Joaquin Local Health District, <br /> Exact Site Address LOT 4 4417 W. STONERZDGE DR. City/Town TIR A CY <br /> Owner's Name Don- Cose Phone 835-0422 <br /> Address 1 9E .....6th S t. City Tracy <br /> Contractor's Name Hennings Bros. Drilling O@icense# 290813 Business Phone 545-1 <br /> Contractor's Address 3525 Pelandale AVe. Emergency Phone — <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No v <br /> TYPE OF WORK (CHECK): NEW WELL Q, DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 1001 Sewer Lines Pit Privy <br /> Sewage Disposal Field 1001 Cesspool/Seepage Pit .I?sf�.._AZ._!,� Other <br /> Property Line A`fPrivate Domestic Well Public Domestic Well A42er <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation �I <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 61.1 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal 501. <br /> ❑ CATHODIC PROTECTION EX ROTARY Type of Grout MtNT <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> — <br /> ❑ GEOPHYSICAL Surface Seal Installed By: DRILLER <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I 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 /> 1 will call for a Grout Insection prior to grouting and a final inspection. �� e <br /> Signed X S• Title: WiCJ Date: _ _��J7 <br /> (Draw Plot Plan on Reverse Side) <br /> F DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By Dat <br /> Additional Comments: <br /> Phase li Grout Inspection Phase III Final Inspection <br /> Inspection By Date Ins ction By ate 1 ' <br /> FEE IS DUB: El ANNUALLY PER UNIT ❑ PER SITE EACH LJ"Ja uary 1 8 Received By January1 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATIONBILLING <br /> DATE REMITTED MOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> U3 <br /> Received by JDate I Receipt No. Permit;No. I uanc Dat Mailed Delivered <br /> .— APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM IT/$EFIVICE9, ��1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />