SR0080452_SSNL - Laserfiche WebLink

Home Browse Search

App( r 6rsl�ed." the matted Properly Completed.Be Sure To Sign The Application. FOR OFFICE USE: i i PPLiCATION - INJBIV 2,1 Non-Transferable,Revocable,Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT 'Q1 'n L�� WATER QUALITY , (COMPLETE IN TRIPLICATE) t EI{- �,T�fi�� _ . • '"- r '"� tr Application is hereby made to the ' r Jsaqu�L'SL`"�fNd'd'l7nistrictforapermittoconstructand/or install the work,herein described.This application is made in compliance w' h San J @quin ounty.Ordinance No. 1862,and the rules and regullations of the San Joaquin Local Health District. Exact Site AddressE.2GU �1.1a�L City/Town +a C}�— — Owner's Name P tone Address _____' CCsr-�-� �1 - Ci y.— — Contractor's Name _Machado�c'!�r License ff�19�� Business-Phone Contractor's Address "�.2—— Qr '�1 _ Emergency P ne �D 2 —--� Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No __ 1 TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION DESTRUCTION C1 WELL CHLORINATION❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATiONX PUMP REPAIR❑ O 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 ❑ CABLE TOOL Dia.of Weil Excavation- I 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 - -- ❑ DISPOSAL ❑ OTHER Other Information - - ❑ GEOPHYSICAL .. : Surface Seal Installed By: PUMP INSTALLATION: Contractor -- Type of Pump H..P.. -- PUMP REPLACEMENT: E State Work Done PUMP REPAIR: 0 State Work Done DESTRUCTION OF WELL: Well Diameter __ Approximate Depth — _w_._ -Describe Material and.Procedure I hereby certify that I4have 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 for which this permit is issued, I shall employ pe ons sub'ect to workman's compensation laws of California." r 11 c for a Grout In ec n rior t routing a final Inspection. Signed X Title: Date: —1V - (Dra of Plan on Reverse Side) d � FOR DEPARTMENT USE ONLY PHASE 1 PQM �R_ (�An �� `1-a3- • Application Accepted By ' — Date. Additional Commenls: I - (Phase11 Grout Inspection 1 �'y�P�hase III Final lnspactlonIS Inspection By . /a Date Inspection By ,�� Date �' �- �� Fee Is Due: ❑ ANNUM LY f❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January' &Received By January 31 ❑ July 1 6 Rece,cl By July 31_ REMIT BASE EXPLANATION BILLING REMITTANCE l S AMOUNT DUE CHECKED DATE DATE: 4I REMITTED AMOUNT FEE u� /�= LESS PRORATION - PLUS PENALTY --- OTHER THER - Received by Date -• Receipt No - Permit No Nsuame Date Mailed Delivered )APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95205 .rL�