81-24 - Laserfiche WebLink

Home Browse Search

Applications Will Be Processed When SubmittedProperlyCompleted. Be SureToSignTheApplication. FOR OFFICE USE: 0 APPLICATION 3 (For Non-Transferable, Revocable, Suspendable) PUMP&WELL 31 ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby madeto the San Joaquin Local Health Districtfora permit to construct and/or install thework herein described.This application is made in compliance with Loc Healt (strict. San Joaquin o nth.r inanc�}_No 1862 and th rul s and regulations of the San Joaquin h Exact Site Address , �_ f° Y`Q. City/Town -l�G� ® F T- - TOwner's Name � 11 • Phone Address ,fes /A.S7 \r�7�-:2h 3L-Is , City_ {��k Contractor's Name 44a P_ l S6 13 m4- S L[iic��ense,#�� '/9 Business Phone a f�`/��'y Contractor's Address ! A- ,I �rgency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ti>4= No r' TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIO WPUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank )e-)9Q Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other ProProperty p y Lin s Private DomesEic Well Public Domestic Well INTENDED USE '"""""" "*"TYPE OF WELL' — - �� 3 " y " — - �1 ❑ I14DUSTRIAL CABLE TOOL Dia. of Well Excavation - j 1 OMESTIC/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 S,2 df ❑'DISPOSAL i - ❑ OTHER- Other InforrnationJ--- - --�-- - - ri ❑ GEOPHYSICAL Surface Seal Installed By: PUMP-INSTALLATION: 1P Contractor �' 7 i �� . . • Type of Pump .!5- 11A Itf '' H.P. PUMP REPLACEMENT: El State Work Done. 421 � ' PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: , t Well Diallieter ? � -- Approximate Depth +}} Describe Material and Procedure L__f t 1 I hereby certify that I 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. t {' Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit f *o- 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 �# i permit is issued, I shall employ persons subject to workman's compensation laws of California." l[ € 1 will c II for a Grout Inspection prior to}grouting and a final inspection. ( � Signed X -�1 A,&A4 Title: Q }, Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I r��`nyn� � w i Application Accepted By -1 1 t� `rO� Date l f Additional Comments: P II Gro t nspection Ph 11 Final spection� Inspection By Date /�4/ Inspection By Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 to July 1 &Received By July 31 REMIT r BILLING REMITTANCE $ I BASE EXPLANATION AMOUNT OUE CHECKED DATE DATE REMITTED AMOUNT i FEE LESS PRORATION I PLUS PENALTY I } OTHER OTHER e �aa5 1 s • Received by Date Receipt No. Permit No, Itsuancd Dald Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 !