81-907 - Laserfiche WebLink

Home Browse Search

" Its- I[y Applications Will Be Processed When Submitted Properly Completed.e Bee u � ��:,� MINTRIPLICATE) APPLICATION (For Non-Transferable, Revocable,Suspendable) &WELL ENVIRONMENTAL-HEALTH PERMIT DEC WATER QUALITY,;,. � r. dLri �sfPI2 §f� Application is hereby madetothe San Joaquin Local Health Districtfora permit tocon&t4uctand/or install the work.herei made in Compliance with.San Joaquin County Ordinance No. 1.862 and.the.rules.and.regulations�of the San Joaquin L ��aTi D �s� ICT 5 City/Town Exact Site Address . d,+.;+;� Phone~ # Owner's Name y. r City" Address S �s License# Business Phone Contractor's Name ' /�' Emergency Phone� ''•1 Contractor's Address &e'A6^1 /gal 1 �6 5 l/� g y No Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes = TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECO�1T1 P❑P INSTALLATION O PUMP REPAIR WELL CHLORINATION.❑ WELL ABANDONMENT ❑ OTHER REPLACEMENT❑ 1 Sewer Lines Pit Privy DISTANCE TO NEAREST: Septic Tank e Pit OtherS cesspool/Seepage Sewage Disposal Field C�, Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL 6INDUSTRIAL 11CABLE TOOL Dia. of Well Excavation DOMESTIC/PRIVATE 11DRILLED Dia. of Well Casing DOMESTIC/PUBLIC 0 DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal C1CATHODIC PROTECTION 13ROTARY _ Type of Grout ❑ DISPOSAL ❑ OTHER - Other Information C1 GEOPHYSICAL. Surface Seal Installed By: PUMP INSTALLATION: Contractor H-P. Type of Pump PUMP REPLACEMENT: ❑ to Work Done Work Done t IY State 'r' PUMP REPAIR: Approximate Depth ! DESTRUCTION OF WELL: Well Diameter' Describe Material and Procedure S I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County ti ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work 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:"I certify that in the performance of the work forwhich this permit is issued, I shall employ persons subject to workman's compensation laws of California." I will call for a Grout Inspection prior,to grouting and a final inspection: Date:.12�� X Title: Signed Reverse r' (Draw Plot Plan on ide) FOR DEPARTMENT USE ONLY . PHASE I ` Date Application Accepted By Additional Comments: as na.- � ection Phase It Grout Inspection Date Inspection By_ bate Inspection By 1 Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH,I- ❑ January 1 &Received By January 31 El July 1 &Received By July 31 REMIT 1 BILLING. REMITTANCE AMOUNT DUE CHECKED ' BASE- � EXPLANATION DATE DATE REMITTED AMOUNT FEE LESS PRORATION - PLUS PENALTY OTHER OTHER Received by Date Receipt Ne, ;Permit No. lss nce ate Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.aura 2004 STOCKTON,CA 95201