83-514 - Laserfiche WebLink

Metadata

Thumbnails

Annotations

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 t Of 'v r. 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 tions of theSan J made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regula � Exact Site Address Joggin G Health District.. 9626 Leland '` 'City/Town 7 t ' ` Lo 1:9 'Meneeet !P ' Phorie; X931-2068 - Owner's Name 1 Address aril CiE`r '�� Fr�* :. ' Q_, ; .:- City . t ,... .: Name Moorman' s l"WatOr stems License# ''267696" Business Phone f" 931-3210- Contractor's Contractor's Address 2120 W1.ICOX Rd' fi .r `Emerenvy Phone.� 9 Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes XX No 9 TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ "DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT-.0 OTHER-❑ PUMP INSTALLATION ZX PUMP REPAIR REPLACEMENT❑ i 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 i ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ' ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION .� 0 GRAVEL PACK Depfh of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ; yl ❑ DISPOSAL ❑ OTHER Other Information r 11 GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Moorman' s Water System r I -Type of Pump subm rsible H.P.' PUMP REPLACEMENT: 7 MXtate Work Done replaced exi stincy numnwith new 1HP PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: I' Well Diameter Approximate Depth s 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. k Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit I is issued, I shall riot employ any person in such manner as to become subject to workman's compensation laws of California." Conlractor'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. - Signed X Title: — Date: (Draw Plot Plan on Reverse Side) t t d •F i FOR DEPARTMENT USE ONLY PHASE I Oat i Application Accepted -y Additional Comments _ - Phase II Grou Inspection Phase 111 Final Inspection Inspection By - ;Dale Inspection 8y �' - Date # „ Fee Is Due- ❑ ANNUALLY': . -PER UNIT ❑ PER SITE El EACH ❑ January 1'&Received By January 31 July 1 &Received By July 31 � I - REMIT BASE EXPLANATION'"" BILLING s REMITTANCE $ AMOUNT DUE' CHECKED (� DATE DATE' REMITTED AMOUNT -I' FEE' 411r - n LESS PRORATION PLUS K+ i ` _ r F PENALTY, OTHER # s. OTHER - Received-by-- '* r-_. -Date.-.,. -'�., Receipt No.' - -Permit No. - .'issuan a Date Mailed Delivered - '+ APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201