05528 - Laserfiche WebLink

Home Browse Search

Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. r FOR -eFFICE USE: APPLICATION (For Non-Transferable, Revocable, Suspendable) PUMP&WALL ENVIRONMENTAL HEALTH PERMIT C►� (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordi ance No. 1862 and the rules a d regulations of the San oaq'uin}ocal Health District. Exact Site Address ► t.t1 AJ C' L ' City/TownAll Owner's Name jAMP932TOMER11111111l Phone Address S ""` CityC. Contractor's Name 7T!,VV, License# c;279070 Business Ph}ne_��'`m�. ) r .r Contractor's Address __Zil P�71 ill/r'-� - - Emergency Phone S4 h� Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes h)J No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR C1 REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL 13 INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ta►DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 11 DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal N ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout IDd ❑ DISPOSAL ❑ OTHER Other Information j ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: Ot State Work Done DESTRUCTION of WELL: Well Diameter Approximate Depth Describe Material and Procedure I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner 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." 1 will for Gr coon prior to grouting and a final inspection Signed X Title: -�/1�l7 f Date: � (Draw Plot Plan on Reverse Side) F R DEPA MENT USE ONLY PHASEI Application Accepted By Date �� Additional Comments: Phase II Grout Inspectioll Phase III Final Inspection Inspection By Date Inspection Date �c4 Fee Is Due: ❑ ANNUALLY - ❑ PER UNIT PER SITE El EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BILLING REMITTANCE $ ' BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER -P-'f-S-) Received by bate Receipt No. - Permit No. - -----:.Issuance Date, �-,-�,Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 " _. _; _-'�_ .._.._.__.a.�.... --,ate' -- �