SU0007558 - Laserfiche WebLink

Home Browse Search

FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable,Suspendab' PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is made in compliance with an Joaquin ounty rdinanc No.1862 t e rules and regulations of the San uin Local Health District. Exact Site Address City/Town , G Owner's Nam GL Phone Address City Contractor's Name r - cense# . 4r / Business Phone -- Contractor's AddressN40 !z Emergency Phone Is Certificate of Workman's Compensa ion Insurance on File With SJLHD? Yes X No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 4 WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONA PUMP REPAIR❑ I REPLACEMENT❑ I DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy 0) Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL (r, ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation �f ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout 4 ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL r Surface Seal Installed By: PUMP INSTALLATION: Contractor Ja - 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 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 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 wl all for a GGfffout Inspection-prior to grouting and a final Inspection, —moi Signed X 1 .14.1 Title: ��2( ([��J Date: 7"��9 4 (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE Application Accepted By— Date Additional Comments: Phase 11 Grout Inspection has III Final Inspection Inspection By Date Inspection By to tw Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 3 ❑ July 1 &Received By July 31 REMIT BILLING REMITTANCE E BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT W FEE in LESS PRORATION PLUS PENALTY OTHER OTHER O -79-\( - i � W /79 Received by Date Receipt No. Permit N6 13uance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 101 E.HAIELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201