Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Beq1rTb <br /> Sibhdie1E4ppVcan1.UHFO l Opp CE-USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendab e) MAR 28 199@ ,p&WELL <br /> . . J�uV1 <br /> VMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) /p r �7 ER QUALITY SAN J �.O�JILOCAL <br /> n' T t f <br /> Application is hereby madeto the San Joaquin Local e�IthDistrictf�ermittoconstruct and/or instafl14,�1Nerk< efc e�'+b d.Th is application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San LQaDquin Lq S e I tXi tl <br /> Exact Site Addre S Y RD S 0 COLLIER ROAD City/Town UU 11 <br /> Owner's Name ?1 NORM DEN Phone <br /> Address City <br /> Contractor's Name SAN JOAQUIN PHMP CO. License#381012 Business Phone SAME <br /> Contractor's Address860 E. PINE ST, LODI, CA 95240 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL 13DEEPEN 11RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION MX PUMP REPAIR 11 <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 Dia. of Well Casing r <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ? <br />'i ❑ ROTARY Type of Grout p . <br /> ❑ CATHODIC PROTECTION �+ <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: 00 <br /> PUMP INSTALLATION: Contractor SAN JOA UIN PUMP CO. 20 LTJ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> Approximate i DESTRUCTION OF WELL: Well Diameter 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 /> Home owner or licensed agent's signature certifies the fallowing:"I certify that in the performance of the work for which this permit <br />'r is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> t 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 /> I wit a Gro Ins r' to g uting and a final inspection. <br /> Signed X Title: OFFICE MGR Date: 26 MAR 80 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR EPARTMENT USE ONLY <br /> PHASE ] /J � <br /> Application Accepted By Date <br /> [ Additional Comments: <br /> Phase II Grout Inspection - ` /� Ph Final I ectiow/ <br /> Inspection By Date /� Inspection ByAt Date Y� <br /> Feels Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> RASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE cREMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> i <br /> Received by -Date Receipt No. Permit No. Issuance Date Mailed "Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES- 1601 E.RAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />