Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completad. S14eq6 Sign TheApplication. <br /> FOR OFFICE USE: APPLICATION O 6 19 <br /> (For Non-Transferable, Revocable,Su abl ] + <br /> ENVIRONMENTAL HEALTH P RMIT i3\ 1 J� /WELL! <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) Cj � �iN <br /> t Application is hereby made to the San Joaquin Local Health Districtforapermit toconstruct and/or Lrivi�r1t�"workherein, desced.This application is <br /> ! made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 241 K10 Rd[' City/Town Lathrop <br /> 982-0198 <br /> Owner's Name 5aTThomas Gannon Phone <br /> Address City e <br /> Contractor's Name Mo rman1 jii� t r stems License# 26769£_ Business Phone 931--3210 <br /> Contractor's Address 4241_ herryl and AVP-- Emergency P�h.,one <br /> same - <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ J �, <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ V l <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> + Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> i , <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> *DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Moorman' s Water Systems <br /> i Type of Pump submersible H.P. 1 <br /> PUMP REPLACEMENT: ' <br /> ❑ State Work Done <br /> PUMP REPAIR: 13 State Work Done <br /> E DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> i <br /> Describe Material and Procedure <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 /> i <br /> F Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, I shall not-employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X _ Title: s Date: <br /> (Draw Plot Plan on Reverse Side) <br /> G FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Ph a III Final Inspection, <br /> Inspection By Date Inspection By Date <br /> I <br /> k Fee Is Due: ElANNUALLY ElPER UNIT ElPER SITE ElEACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> RASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> i LESS <br /> PRORATION - - - <br /> PLUS <br /> PENALTY <br /> rr OTHER <br /> 1 <br /> OTHER L_J <br /> �a,3. <br /> Received by - Date Receipt No Permit No. lssuanc6 Dae Mailed Delivered - <br /> l;? APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.14AZELTON AVE.,P.O.Box 2009 STOCKTONICA 95201 <br />