SU0010864 - Laserfiche WebLink

Home Browse Search

Applications WIII 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) �36 p Lc, J{0G•rtk✓ W •WATER QUALITY ' Application is hereby made to the S nJoaquin 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. , Exact Site Address �-`� ' . �e -� ''«'r 2t�/Town Owner's Name -� - - _ - Phone ' Address_ZO_L� � OIH Contractor's Name License#/. 1323 Busines Phone Emergency Phone I-y� ` )LJ-7 1 Contractor's Address h . Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes t/ No TYPE OF WORK (CHECK): NEW WELL 13 DEEPEN ❑ RECONDITION❑ DESTRUCTION[] - WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR 13 � REPLACEMENT11d" 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 ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia.of Well Casing f Q-DWESTIC/PUB ❑ DRIVEN ' Gauge of Casing *`,,rt: RRIGATI- ❑-GRAVEL.P-ACK_ DepthALGrout.Seal . ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ` I ❑ DISPOSAL t ❑ OTHER Other information ❑ GEOPHYSICAL'+ N: 6P� �S urfac tailed By: �• - E PUMP INSTALLATION: Contractor a Type of Pump 'T � �/ H.P. r PUMP REPLACEMENT: tate Work Done- lOr7`��. s--+ /) t9. D� n,y_.,,,✓— 3 V � � •r PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter (Approxi ate Depth r' Describe Material and Procedure ' 1 C 1 hereby certify that I have prepared this application and that the work will be done in accords;ce with San Joaquin County ordinances; state laws,and rules and regulations of the San'Joaq Ulh•Local Health District. 1 Hom o nerorllcensedagent'ssignature certifies the following:"I certiry that inthe performance oftheworkforwhich this permit is issued, 1 shall not employ any person in such manner as to become subject to workrrlen's compensation laws of California" Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for wh ich this permit is issued, I shall employ persons subject to workman's compensation laws of California." I w) all for a Grout IRS action prior to grouting and a final Inspection. Signed X 1`` .�`i �•- >n �'�~ /�Tige: Date: (Draw Plot Plan on Reverse ide) �, r"- (. FOR DEPARTMENT USE ONLY fv r PHASE I. `f1., GL In Applicatidn Accepted..,. ` Date I _ 1 ) Additional Com_ments:, I' I f 1 -Phase 11 Grout Inspection h 111 Final Inspection L . Inspection By Date Inspection By Date q'�V ,� f Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July 1 S Received!By July 31 BASE EXPLANATION MIT BILLING REMITTANCE E AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT 1� FEE 1 { LESS PRORATION _ .. PLUS PENALTY OTHER `. OTHER 31 y �- .. No. Issuancal Data Mailed Delivered .