SU0004545 SSNL - Laserfiche WebLink

Home Browse Search

FOR OFFICE USE: t \J' APPLICATION AUG 1,t(For t3e�(w1fansferable,Revocable,Suspendable) PUMP &WELL 'CPQ O Itt%PONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) SP,N`�(��'(N WATER QUALITY Application is hereby made to the Sanytlet{_uin Local Health District for a permit to construct and/or install the work herein described.This application is made in compliance with San Joaqu n C my r o. 1862 and the rules and re ulations of the San J aquin Local Health District. Exact Site Address r I 2V'W d Q City/Town �/ �jPL/ S Owner's Name © Phone Address - 0, City 1/•.��'//�J h 3 Contractor's Name C - License# 1g Business Phone .5,;Ls4 a7 J Contractor's Address Emergency Phone � . .____ Z. Is Certificate of Workman's Co pensationIns rance on File With SJLHO? Yes No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR REPLACEMENT❑ /��.I� DISTANCE TO NEAREST: Septic Tank �f-K Sewer Lines fl� / Pit Privy Sewage Disposal Field //O t, Cesspool/Seepage Pit Other_ Property Line 1VV r Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation /..– , P<POMESTIC/PRIVATE %DRILLED Dia, of Well Casing � r ❑ DOMESTIC/PUBLIC 11 DRIVEN Gauge of Casing 0 ��(L �C- ❑ IRRIGATION fir.GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information n ❑ GEOPHYSICAL Surface$eal Installed By � t•/i PUMP INSTALLATION: Contractor IA./ _� LI-AW22 (' Type of Pump c1 fJ ___ H.P. PUMP REPLACEMENT: ❑ State Work Done -� PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth —y- Describe Material and Procedure d� L! 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. Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit rJ is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this permit is issued, I shall employ persons subject to workman's compensation laws of California." I will call f r a out Inspecti 6 prior to grouting and a final inspects Signed X - Title: Date: raw Plot Plan on Reverse Side) rl FOR DEPARTMENT USE ONLY PHASEI q Application Accepted By Date / Additional Comments: Phase It Grout Inspection p f2-/I-L/-Iq N d I F al �n*se,(Inspection By C�-' Date 0 Z Inspeciion ByN(-^q _ _ �' te Fee IS Due: ❑ ANNUALLY' ❑ PER UNIT ❑ PER SITE CH ❑ January 11 a Re eivved By January 31 "LJ ly I &Received y Jul 3Y REMIT BILLING REMITTANCE SAW BASE EXPLANATION DAMOUNT DUE CHECKED ATE DATE REMI AMOUNT FEE 43 , -3 LESS PRORATION PLUS PENALTY OTHER OTHER Received by ate I Receipt No. Permit No. Issilance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2003 STOCKTON,CA$5201