SU0007433 - Laserfiche WebLink

Home Browse Search

Fr'-11 OFF':;E USE: APPLICATION r (For Non-Transferable, Revocable,Suspendabl+NOW PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) z�/ �� N,. WATER QUALITY �;'"�` Application is hereby made to the San Joaquin Local HealthDistni t for a permit to construct and/or install the work herein described.This application is made in c �e vyith S Joaqu n Co y nan No;J862 and the rules and regulations of the San a uin Local Health District. ExactdFe?rs 1 City41 /Town __ f Owner's Name Phone Address City p Contractor's Name License#=��Business Phone c ? Contractor's Address a��n = __�� Emergency Phone �"'NQ✓vrAz Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes >< No TYPE OF WORK (CHECK): NEW WELL- DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 2r— PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage,Pit Q � r Other Property Line 3 '7 Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL £ABLE TOOL Dia. of Well Excavation DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 76 ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing C3IRRIGATION C3 GRAVEL PACK Depth of Grout Seal — v ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout --s �+. ❑ DISPOSAL ❑ OTHER Other Information e ❑ GEOPHYSICAL Surface Seal InValled 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 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 o*e 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." G Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this C permit is issued, I shall employ persons subject to workman's compensation laws of California. I will c I for a Grout Inspectionrprior to grouting and a final inspection. l Signed X �Oy rhe--y�1 AAAA A Title: s.1. inn, 2-/'\ Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I (U,�`(n\4L ��3�p� Application Accepted By 1 , ` �� Date ��s-&1 Additional Comments. Ph s '11 Grouninspection 9Phase III Final Inspection_ Inspection By t "` t / Date N �O $ Inspection By Date Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 BILLING REMITTANCE $ REMIT BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED c7 AMOUNT FEE ((� � p�O p LESS PRORATION PLUS PENALTY OTHER OTHER dA a c -- Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bo:2009 STOCKTON,CA 95201