Laserfiche WebLink
Applications Will Be Processed When Submitted ProperlyCompleted 13ebure�,opj n � e tIcatw�� <br /> FOR OFFICE USE: APPLICATIO s U <br /> 1� <br /> g •�� (For Non-Transferable, Revocabl s 1 1 <br /> �r� S MP&WELL f <br /> ENVIRONMENTAL HEAL RMI <br /> 1981 y ` <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY /fib <br /> Application madetotheSanJoaquin Local Health Dlstrictforapermit toconstruct and/or irls"I"!M1 mgor�c I n <br /> d.Thisapplicationt <br /> pp Y <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and reA Ions J90 �iP( Local Health Distract. <br /> Exact Site Address_1753_5 E. K�ttl�trLar�I Z12. P <br /> Owner's Name Dorothy Hemsley Phone <br /> Address 17535 E. Kettleman Ln, city---Lad i <br /> Contractor's Name Goehrina Pump & 1rrigatiomense# 309031 Business Phone-----U]----5-54R �t <br /> Contractor's Address 17754 N. Hwy. 88 Lkfd Emergency Phone V1 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes NX No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ J <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 55 PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> tSewa�ewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> D USE TYPE OF WELL <br /> ,}��rIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ,&, C/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ IC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ON ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ IC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ L t'" OTHER Other Information <br /> ❑ SICAL Surface Seal Installed By'PULLATION: - i ContractorGOehri3lCgumpType of Pump submersible N.P. <br /> PCEM ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure V1 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws;and rules and regulations of the San Joaquin Local'Health District. <br /> Homeowner or licensed agent's signature certifies the following:.1 certify tl fat in the performance of the work for which this permit <br /> is issued, I shall not empi4y any person in such manner as to beconl a subject to workman's,compensation laws of California." <br /> Contractor's hirm orkub-co r cling signature certifies the following: certify that in the performance of the work for which this <br /> permit iS iss I hall e I persons subject to workman's compensation laws of California." . <br /> I will tali f r out In on for to grouting and a final inspection. <br /> Signed X Title: knr Date: 0710BZ81 <br /> (Draw Plot Plan on Reverse Side) v <br /> - M FOR DEPARTMENT USE ONLY <br /> PHASE 1 1� , Ot —q 12 <br /> Application Accepted By ..r++ Date <br /> Additiogal C merits: <br /> L4.o1T. "-L— _, _ -- _ <br /> P}aIha a HI Final inspection <br /> se 11�Grou1nspection 1 <br /> Inspection By Date Inspection By Date {/ <br /> o <br /> Fee IS Due: ❑ ANNUALLY ! ❑ PER UNIT ❑ PER SETS ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 R Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REWTTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> i <br /> OTHER <br /> —7 <br /> Received by Date Receipt No. Permit No. Issuance D to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />