SU0007558 - Laserfiche WebLink

Home Browse Search

npyuwuw ra nw oe rwwaasu nota auwuumu rreyeny v.vruyierev. oe awe I V algn lire npyuaauou. FOI:`OFFW,USE: APPLICATION -- (For Non-Transferable, Revocable,Suspendab'.., PUMP &WELL 11 ENVIRONMENTAL HEALTH PERMIT .121, (COMPLETE IN TRIPLICATE) WATER QUALITY .0 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 w 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 5105 Lovely Rd.-between Old Hwy0 & Biri*rR 1rs9 north Gide, Tra ny Owner's Name Joe Cuesta Phone 835-O441 Address 5105 Lovely Rd, City Track Contractor's Name Heinnin S BrOs• License p 29081 1 Business Phone 545-1185 Contractor's Address= Pelandale ll Mod* Ca o Emergency Phone 545-0271 i Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No O TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank 1 1 1 It Sewer Lines Pit Privy Sewage Disposal Field 1111+ Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL to ❑ INDUSTRIAL ❑ CABLE TOOL Dia.of Well Excavation 1 3n EI DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing $N PVC ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 160 WALL M IRRIGATION M GRAVEL PACK Depth of Grout Seal 501 ❑ CATHODIC PROTECTION M ROTARY TypeofGrout BENTONITE ❑ DISPOSAL ❑ OTHER Other Information SLAB-BY OWNER ❑ GEOPHYSICAL Surface Seal Installed By: DRILLER 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 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 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, 1 shall employ persons subject to workman's compensation laws of California:' I will call for a Grout Inspection prior to grouting and a final Inspection. /A Signed X Title: XJGDale: F-13�'T9 ly (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE Application Accepted By Date Additional Comments: Phase 11 Grout Inspection Phase III Final Inspection Inspection ByD Pa. Inspection By ate l IV-70-2p) Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 'IIYU PER SITEEAC ❑ January 1 d Received By January 31 ❑ July 1 a Received By July 31 BILLING REMITTANCE $ REMIT BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE AILA 2i LESS PRORATION PLUS PENALTY OTHER OTHER —q 7 Received by Data Receipt No. Permit No. Lsauance Data Mailed Delivered Te/7 APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE., .O.aoa 3008 STOCKTON, A YalOT