SU0012964 - Laserfiche WebLink

Home Browse Search

AMiicawn's Wfll"b6ro%esti of*R 44 Submitted Properly Completed.Be Sure To Sign The Application. FOR OFFICE USE: , �^ APPLICATION , DEC 15 1 „(For Non-Transferable, Revocable,Suspefidable) � PUMP&WELL f l�}(O2- 4 _Sht.J_t'-E`�tS E VIRONMENTAL HEALTH PERMIT •i SAN JCAQ�" � {COMPLETE IN TRIPLICATINEA T� DW.R WATER QUALITY Z�- O Application is hereby made totheSanJoaquin LOce althDistrict for apermit toconstruct and/or install the work herein described.This application is made in compliance h San Joaquin Co my Ord'ngpce No. 1862 and the rules and r gulations of the San Joaquin Local Hea h District. Exact Site Address.A// ' u�Q�`1LU�Q / L_ City/Town./��iV - Owner's Nance Phone- )��7 0706 _ Address ��[��A.� l _ City Contractor's Namecense# -d?908/_3 Business Phone .5�:111?5 - Contractors AddressEmergency Phone __. �...... _ Is Certificate of Workman's Compensation Insurance on File/With SJLHD-1 Yes_� No TYPE OF WORK (CHECK): ' NEW WELL DEEPEN ❑_ - RECONDITION❑ - DESTRUCTION❑-- t WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines r' _ Pit Privy V , 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 Well Excavation DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing . �Hn ❑ IRRIGATION 0,GRAVEL PACK Depth of Grout Seal 3F 0 ❑ CATHODIC PROTECTION XROTAR- Y Type of Grout —_ �7 T I ❑ DISPOSAL ❑ OTHER _ Other Information 11GEOPHYSICAL. Surface Seal Installed By: _ L /EG��o PUMP INSTALLATION: Contractor Type of Pump - i ; H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: 0 State Work Done - - - - DESTRUCTION OF WELL: Well Diameter_ Approximate Depth Describe Material and Procedure 1 hereby certify that I have prepared this application and that the work will be done in'accordance wittr.San Joaquin County I l ordinances,state laws, and rules and regulAtions of the San Joaquin Local Health District ., v3 Homeowner or licensed agent's signature certifies the following:-"I certify,that in the performance of the worKfor 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." r} Contractor's hiring or sub-contracting signature certifies the following:"I�e�tify.that in-ea performance of the'work for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." I will all for a`Grout Ins ionnprior to grouting an a linal ins on. . J u Signed X 1 Date: t `(Draw PI Plan on Revq se Side) ' FOR DEPARTMENT USE ONLY i PHASE I Application Accepted B 1�" V Date Additional Comments: - Phase mi InspectionPhase Ill Final Inspection Inspection By Date Inspection By_.-_ ...._.- Date Fee Is Due: ❑'ANNUALLY ❑ PER UNIT ❑ PER SITE .❑ EACH- ❑ January 1 1(Received By January 31 -❑ July 1 d RcMe 0d By hry 3' REMIT ' BASE FFPLANATION BILLING REMITTANCE - S AMOUNT 7UE CHECKED DALE DATE REMITTED AMOUNT _ I FEE i LESS PRORATION -- Pl US I PENALTY, k 1k, _. OTHER OTHER f •L, '` \ \, Received by Da .- Receipt No. ' - ,ti Pe•mit No Issuance DT. Mailed nelivered _ 1 APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HA2ELTON AVE.,P.O_Bos 2009 STOCKTON,CA 95201 I