Laserfiche WebLink
-- _ _ ..' , <br /> Z Applications Will Be Processed When Subm e <br /> _ : APPLICATION <br /> I}CE USE: <br /> (For Nov-Transferable, Suspendabie) PUMP&WELL � <br />..��:�� is� ��' _ — '— '�— rz• ...�Y" "—�r'�� <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE)�� <br /> Application is hereby made to the San JoaquinLocaiHealthl4Ds1g62or aphe runes and regulations of the Sanorkaquinl Local Healdth District.,This application Is <br /> made in compliance with San Joaquin County Ordinanc City/Town <br /> Exact Site Address s <br /> Phone i <br /> Owner's Name City <br /> f Address ► License#3 Business Phone <br /> Contractor's Name Emergency Phone _ <br /> 9 Contractor's Address ' No <br /> I Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes r <br /> DESTRU <br /> TYPE OF WORK (CHEGK❑1'. hWELLy ABANN,DODEEPEN NMENT ❑❑ -OTHER❑ ITIOPP MP INSTALLAT OIN�+ PUMP REPAIR[3 � Iti <br /> WELL CHLORINATION <br /> REPLACEMENT❑ Sewer Lines __�I 44ji Pit I t <br /> '� ' Other �- <br /> DISTANCE TO NEAREST: Septic Tank Cess' o�'l7Seepate P,It <br /> I Sewage Disposal Field-___.. . . — "i <br /> Public Domestic Well <br /> Property Line �-Private Domestic Well Y <br /> TYPE OF WELL I C <br /> INTENDED USE _. pia. of Weil Excavation <br /> ❑ INDUSTRIAL CABLE TOOL <br /> e °` Dia. of Well Casing t. <br /> I DOMESTIC/PRIVATE-- �� ❑DRILLED <br /> ❑�D1!IVEN Gauge of Casing } <br /> I ❑ DOMESTIC/PUBLIC ❑';GRAVEL PACK Type Depth of Grout Seal <br /> ❑ IRRIGATION Te o1 Grout <br /> 11 CATHODIC PRO ❑ ROTARY PROTECTION 13OTHER Other Information <br /> I; I!� <br /> ❑ DISPOSALa Surface Seal Installed By: I� <br /> r ❑ GEOPHYSICAL f <br /> PUMP INSTALLATION: Contractor H.P. <br /> r i Type of Pump <br /> 11 State Work Done <br /> PUMP REPLACEMENT: ❑ State Work Done $� <br /> PUMP REPAIR: Approximate Depth <br /> Well Diameter <br /> DESTRUCTION ORWI=LL: <br /> f Describe Material and Procedure <br /> f <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County i� ILI <br /> r ordiriances, state laws, and rules and regulations of the San Joagciertify al nthepeHealth sformanceottheworkforwhichthispermit 4 <br /> Home owner or licensed agent's signature certifies the manner <br /> as ng:' <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." - <br /> r following: y �+�xt <br /> Contractor's hiring or sub-contracting signature certifies kman scompens teanflaws tof.Califrniia performance of the work forwhich this <br /> i permit is issued, I shall-employ persons subject to wo <br /> 1 R <br /> I will Cali for a Grout Inspection prior to'grouting and a final inspection. Date: <br /> Title: <br /> iSigned X (Draw Plot Plan on Reverse Side) *; <br /> F R DEP RTMENT SE ONLY <br /> 1 PHASE I=` 1 41^_e'(/ Date 7 �,! IJ <br /> Application Accepted By Es' <br /> � � til <br /> Additional Comments: Phase 111 Final Inspection <br /> Ph a II Grout inspection <br /> ` Date 6�� Inspection By Da� h <br /> Inspecti tn-By �� •� <br /> F I i r ❑ EACH ❑ January 1 &Received By.lanuary ❑ July 1 &Received Ry Yuly 31 <br /> r PER UN4T PER SITE REMIT <br /> Fee Is Due: ❑ ANNUALLY ❑ $ NT DUE CHECKED <br /> AMau <br /> ,j BILLING REMITTANCE TED - AMOUNT <br /> EMIT s <br /> ATION D ATE - R <br /> i <br /> BASE ExPLAN DATE ; -^+- .• �j�j_ <br /> t FEE ' <br /> LESS ' h <br /> PRORATION <br /> k <br /> PLUS ) <br /> PENALTY <br /> {,.. OTHER r <br /> a <br /> .. - OTHER <br /> —Ia1 <br /> Issuance Date Mailed Delivered . <br /> Date Receipt No.ppPLICANBax 2009 <br /> Permit No. CA 95201 1 <br /> Received 6y ,- 1601 E.HAZELTON AVE., .O. STOCKTON, ;I I� <br /> T—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES P { <br />