Laserfiche WebLink
,vppncanons� wnitseProcessedWhen Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: !a APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PLUMP&WELL <br /> — ENVIRONMENTAL HEALTH PERMIT IZ7 <br /> (COMPLETE IN TRIPLICATE ,� f�1 yWAT R .QUALITY O —z�c_[� <br /> ) �r7i2S�7`-, �c ' <br /> Application is hereby made to the San Joaquin Local Health Distnctfora perrnitto construct and/or install the work herein described.This application ill-),) <br /> made in compliance with San Joaquin County Ordinance No. 1862 and jhee rules and regulations of the San Joa Loc ealth District. <br /> Exact Site Address l City/Town ,�.,, <br /> a•c .r��407 o yrs Ar r 'y <br /> Owner's Name A— � ek , Phone <br /> Address e a pV4-V City <br /> Contractor's Name a w.- License# 1�372-s� Business Phone �1' '�,�7 G <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With S HD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN 11 RECONDITION Cl' DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMPREPAIR N <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED pia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing }} <br /> ;} IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal �J - <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout Lel <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: _l <br /> PUMP INSTALLATION: Contractor(_ ,i ce . 'a—A <br /> Type of Pump LIA W H.P. 460 <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done —C� m 60.dr owod6, .4f+_1014K p'n A.- <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 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 forwhich this N <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I W01 call for a Grout In on p 'or to grou ng an final inspection. <br /> Signed Title: 0%z Date: AV <br /> (Draw PI Plan on Reverse Side) `1 <br /> FOR PARTM T USE ONLY <br /> PHASEI <br /> Application Accepted By "^- Date <br /> Additional Comments: <br /> Phase II Grout Inspection se Ill1Fi n <br /> Inspection By Date Inspection By at <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Rec Zved y January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> a.� <br /> LESS <br /> PRORATION <br /> PLUS T <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 1 <br /> Received by - Date Receipt No, Permit No. issuance Date Mailed Dedvered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />