80-431 (2) - Laserfiche WebLink

Home Browse Search

-,,,_,,Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION (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 fora permit to construct and/or install the work herein described.This application is made in compliance with San Joa uin County Or an e No. 1862 and the rules and regulati ns o th San J a�quin ocal Hea strict. Exact Site Address Owner's Name Phone Address f�i& City Contractor's Name License# 7Uy Business Phone 3 t Contractor's Address Emergency Phone gI Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ Y WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ REPLACEMENT❑ �A DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line'-Privatemestic Well Public Domestic Well INTENDED USE TYPE OF WELL �/ �i ❑ INDUSTRIAL CABLE TOOL Dia�of Well Excavation l - } DOMESTIC/PRIVATE &DRILLED Dia. of Well Casing © DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing i 9 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL] ❑ OTHER Other Information \ © GEOPHYSICAL Surface S I Installed By: PUMP INSTALLATION: Contractor Type of Pump A�.f H.P. 1 PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done Approximate roximate De th DESTRUCTION OF WELL: Well Diameter . PP P y� Describe Material and Procedure r J # I.hereby certify-that-1-have prepared this application and?that the work-w ll-be done in-accordance-with San Joaquiri County ordinances, state laws, and rules and'regulat onsrof'Ah�S Joaquin hoc dHealth district. #t Home owner or licensed agent's signature certifles the following:"I certify thaYdn the performance of hework 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: 'tel ee t fy that in the,performance of the work for which this `permit is issued, I shall employ persons subject to workman's pen sation laws of California." :I will call fpr a Grout Inspecti prior to grouting and a final inspection. * Signed X Title: Date: (thaw Plot Plan on Reverse Side) L-11 I ! FOR DEPARTMENT USE ONLY �. PHASE tDated� Q Applicafion Accepted By 4 V 7 Additional Comments: Phase II Grout Inspection Phase III Final Inspection Inspection By ""^ th Dater Inspection By Date 6 k •,. Fee Is Due: ❑_.ANNUALLY ❑ PER UNIT WPER SITE ❑ EACH ❑ January 1 &RL.N By January 31 ❑ July 1 &Received By July 31 k REMIT RASE EXPLANATION BILLING REMETTANCE $ AMOUNT DUE CHECKED ` DATE DATE REMITTED .AMOUNT FEE LESS - PRORATION PLUS PENALTY - -- OTHER OTHER .. .�....--.._ 3 33 Date- �� aPt No' ' �^^" Permit r* Issuance Date �- Maited Deiivered - Received by - ^' APPLICANT-RETURN ALL COPIES TO7 NYIRONMENTAL HE TH PERMIT/SEYtCES � --1601•E.HAZELTON AVE,P.O.Bok 20U9 -STOCKTON,CA 95201.