SU0011066 SSCRPT - Laserfiche WebLink

Home Browse Search

Applications Will Be Processed Whop Submitted Properly Completed.Be Sure To Sign The Application, FOR OMINTRIPLICATE) .I, I, 7�PPLICATION f (For Non-Trariderab*Revocable,Suspendable) PUMP At WELL ENVIRONMENTAL HEALTH-PERMIT MPLETE .. .. _ ::i ,,at.v'�.Zji70I�y�ALITY . , plication is here by made to the San Joaquin Local Health District for a- r locoristru'ctand/orinstalI the work herein described.his application is made in compliance with SaJoaquin Co�upty Ordinance No. 1862 and the'rules and regulations of the Sen Joaquin Local Health District. Exact Site AtltlressA �, ✓aNt�O fV / / lied —S!wi ,1millf 0 City/Town ' �{'/1 f , Owner's Name [.-,Q641�/1 �� UlQtraar -' ' � � ��" •� Phone Address /5/-�!R f'fesnll Clry . . ., .._.` Contractor's Name OtoL/ License74d- Business Phone' Contractor's Address6AI<Fsr:... r :Emergency Phone Is Certificate of Workman's Compensation Insurance o File With SJLHp? Yes A No I TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN 13 ' RECONDITION❑ 'DESTRUCTION❑ - - WELL CHLORINATION❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIRS 1J REPLACEMENT❑ t DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Feld -- Cesspool/Seepage Pit Other Property Line Private Domestic Well____ Public Domestic,Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia.of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing .IRRIGATION .. 13 GRAVEL PACK Depth of Grout Seat ' ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ ' DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed B . y.. PUMP INSTALLATION: Contractor_ 'C 4AMy JEr w,b --4.1 Type of Pump =P4 >4&V V H.P. PUMP REPLACEMENT: ❑ State Work Done t PUMP REPAIR: 19 State Work Done r �TRUCTION OF WELL: Well Diameter r. N6 r1�0 ApproXimate Depth Of Describe Material and Procedure ` t . I hereby certify that I have prepared this Application and that the work will be done in aecprdanee with San Joaquin County ordinances,state laws, and rules and regulations of the San Joaquin Local Health District. i Homeowner orileensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit Is Issued„ shall not employ any persorrin such manner as to become subject to workman's,compensation Igws Of California.,, Contractoes hiring or sub-contro ct(dg signature certilles the following:"I certify that in the performance of theRvork forwhich this permit is issued, I shall employ personssubject to workman's compensation laws of California." I VII call for a Grout Inspect[ dorj/W 6utl Ind a�t)Inlalinspecticn Signedi4� �H �f..! ✓ -� Dale: ! v� (Draw Plot PI on Reverse Side) FOR DEPARTMENT USE ONLY r`� PHASE I Application Accepted By` Dom-^^^-/ Ai"i Ct t7S Date u _��-o I Additional Comments: Phase 11 Grout Inspection Mfi 111 F I I 4 Inspection By � Date Inspection"E' ,� Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE 11 EACH' ❑ J`—1 6 Received anuary 31 ❑July 1 8 Received By July 31 BILLING REMITTANCE.. S REMIT BASE EXPLANATION AMOUNT DUE CHECKED GATE DATE REMITTED FEE AMOUNT 2x -�^'' LESS PRORATION PLUS PENALTY ' OTHER OTHER . Received ey Date ; - .. •. Receipt No. Permit No. :_ Issnce Da _ Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 101 E.HAZELTON AVE,P.O.sor 200 STOCKTON,CA 96281 ,