83-673 - Laserfiche WebLink

Home Browse Search

aP Applications Will Be Processed When.Submltted Properly Completed. Be Sure To Sign The Application. y*FOR OFFICE USE: APPLICATION o- (For Non-Transferable, Revocable,Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY 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 made in compliance with San Joaquin County Ordinance No. 1&62 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address �Zyf-Pro/ /1/' e ,-et A a� /fid City/Town ,41aa a Owner's Name LtY"T /�R°� ai ,'T Phone - �� `f 0 �/! Address / t Bid& Co cam" nr-1 Contractor's Name License#Q��-'7 Business Phone .36'df 7 'Y 0pQ Contractor's Address -4-A-41170 /ll.,.5� 0 Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No t 1 TYPE-OF,WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATdON.❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONS — PUMP REPAIR❑ --..I REPLACEMEN_T_❑ •r t f DISTANCE TO NEAREST: 'Septic Tank ®7t? Sewer Lines/ZL,tC/ PitPricy i Sewage Disposal Field /(IaAl e_. Cesspool/Seepage Pit,_ AJ&dale-_ Other 4,i` Property Line Private Domestic Weil Public'Domestic Well �� TJ� INTENDED USE TYPE OF WELL © INDUSTRIAL ABLE TOOL Dia. of Well Excavation 42— ZPk�pOMESTIC/PRIVATE DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casingl /2 11 IRRIGATION 11 GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information 11GEOPHYSICAL Surface Seasl Installed By:, 3_11'7r d- e ir` PUMP INSTALLATION: Contractor _�- /,"++` ._ G� �'/�i -T,y, of Pump 3c�� , t ( H.P.�?/!—• P. _ . PUMP REPLACEMENT: ❑ State Work Done'Z PUMP REPAIR: C ❑ State Work Done " `' Ob DESTRUCTION OF WELL: Well Diameter'' ° ' —}_ •� - t ' Approximate Depth Describe Material and Procedure l r I hereby certify that I have prepared this a0p`Ilcation and that the wor'k will be done in accordance with San Joaquin County ordinances, state laws, and rules and regulations of the San Joaquin Local Health;pistrict. Home owner or licensed agent's signature certifies the following:"I certify that in theperformanceof thework forwhich 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, I shall employ persons subje'c-rto"work aJ6's`compensati6n:1aws of'CaIifornia." t I will call for a Grout Inspection prior to grouting and a final inspection. Signed X � - - - 9 i Title: t j Y _ ._--Date: (Draw Plot Plan on Reverse Sidef FOR.DEPARTMENT USE ONLY � � [ PHASE I I Application Accepted By "'�—' IC1 I Date Additional Comments: s Grout Inspection ha II Final Inspection InR.spection By Date ? Inspection Byz� 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 AMOUNT DUE CHECKED REMITTED AMOUNT FEE LESS PRORATION ' PLUS PENALTY OTHER �: a OTHER Received y- - ate L Receipt No, - - ermit No. - - Issu.nce D to Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Sox 2009 STOCKTON,CA 95201 .