SU0003502 - Laserfiche WebLink

Home Browse Search

Appl!L:ations Will Be Proud When Submitted Properly Completed. Be SureLhggnTheApplication. t,=,J V FOR-C3FFICE USE: r APPLICATION DEC 13 �9i9 4 s, ,For Non-Transferable, Revocable,Suspendabl� ENVIRONMENTAL HEALTH PERMIT SAN JQAQ iffli- J ILL W HEALTH DISTRICT J (COMPLETE IN TRIPLICATE) ; WATER QUALITY Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or.instalI the work,herein described.This application is made in compliance with San Joaquin County Ordinance No..1862 and thej rules and regulations of the San Joaquin Local Health District. Exact Site Address 16 %Z(oo W vcS'T City/Town TOC4.2-Tn til Owner's Name 1✓ 5Ll')At 1N Phone Lqrm v �d Address �9 �c L-A?y\ 'C� ' . City Contractor's Name License# 377 Business,Phone 4 �rJa Contractor's Address Emergency Phone L} Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes h No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ j WELL .CHLORINATION ❑ WELL ABANDONMENT 13 OTHER ❑ PUMP INSTALLATION © PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL © INDUSTRIAL C] CABLE TOOL , Dia of Well Excavation I ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of We11 Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal CATHODIC PROTECTION ❑ ROTARY Type of Grout d ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL /� Surface Seal Installed By: PUMP INSTALLATION: Contractor A 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' hereby certify that 1 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,-1 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 ersons subject to orkman's compensation laws of California." wi11 cal for a Grou41n pe prior t grouti Ind a fine! inspection. Signed X Title: _ / �-�� . : Date: (Draw Piot Plan on Reverse Side) F R D ARTMEN USE ONLY PHASE 1 q t1 Application Accepted By 2 17 Datei Additional Comments: Phase It Grout Inspection Phase-III Fina�l/Inspection . Inspection By Date Inspection By, QST Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH , ❑ January 1 &Received By January 31 ❑ July 1 8 Received By July 31 h BILLING REMITTANCE $ REMIT EASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED . AMOUNT FEE LESS E PRORATION PLUS PENALTY OTHER OTHER 3 5.13 Received by _ Date Receipt No. Permit No., kssuance Date Mailed Delivered eN APPLICANT—RETURN ALL COPIES VI TO: ENVIRONMENTAL IIEAI-ru o�o•a•�•^•'••••^-- -----''---- "---'--" wnne - arnrrr