SU0006586 - Laserfiche WebLink

Home Browse Search

ICE USE: APPLICATION , For Non-Transferable, Revocable, Suspendable PUMP St WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin 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. 1852 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address 25 60 Hall Avenue City/Town Stoctton t Owner's NameHaY'ley Murra Phone 465-2498 I Address 2560 Hal3 Avenue City Stockton ' Contractor's Name Clark Well & Equipment License# �� Jr6C Business Phonei462-5597 Contractor's Address 2024 E Charter Way Emergency Phone N A - Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ t9 WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank 1001+ Sewer Lines_100'+ Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL loll ❑ INDUSTRIAL. ❑ CABLE TOOL Dia. of Well Excavation 2 KI DOMESTIC/PRIVATE 11 DRILLED Dia. of Well Casing ❑ DRIVEN Gauge of Casing 6n 11 DOMESTIC/PUBLIC 9 9 ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal C t ❑ CATHODIC PROTECTION ® ROTARY Type of Grout Bentonite 1 ❑ DISPOSAL ❑ OTHER Other Information - R ( ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor — ) Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure F' ; 5q 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. Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit jis 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 for which this per is issued, I shall employ persons subject to workman's compensation laws of California." I w l II for a G t In ion p r to grouting and a final inspection. Signed XMILF Title: Sec-'fres Date: 17 Sep 80 1. (Draw Plot Plan on Reverse Side) ` i FOR DEPARTMENT USE ONLY PHASE I. Application Accepted By `�' '� Date t Additional Comments: l hase 11 Grout Inspection / I trial inspection Inspection By Date 1 15 a Inspection Date F' Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 ece' ed By January 31 ❑ July 1 &Received By July 31 REMIT ON l BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE MITTED AMOUNT �� . FEE LESS f PROS ATION PENALTY G`�'I h esti- Al R c r lG <n�.�cTf ut1< OTHER , t >' Q 9 ,r.J ofr`"f 4 D! e f t OTHER a erg rt/ 30` � t r r 2S ._R' � Ntw ! Received by Date Receipt No. Permit No. Issuan a Date Mailed Delivered V� -� APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERV10E5 1601 E.HAZELTON AVE P.O.Box 2009 STOCKTON, A 95201