80-128 - Laserfiche WebLink

Home Browse Search

_ Applications Will Be Processed When Submitted Properly Completed. Be$IlrlelTo Sign The Application. J 1_J 1 fOR OFr i. Usti: APPLICATION �11�5 MAR 4 1980 Lg:� (For Non-Transferable, Revocable, Suspendable) F PUMP&WELL ENVIRONMENTAL HEALTH PERMIT SAN !r°AQUfN 1..4(_�,AL (COMPLETE IN TRIPLICATE) WATER QUALITY HEALTH DISTRICT Application is hereby madeto theSan Joaquin Local Health Districtfora permitto construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No. 1862 and the r �sf nd regulations of the San Joaquin Local �He)alth District. � Exact Site Address �, N e l �` City/Town CJ 4 2!" t f Owner's Name � - Phone t93 City All C/0 I Address ] Contractor's Name License#I12401 D Business & Phone Gk769 -z2o7 Contractor's Address EmergencyPho a ",_e_1Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 09 No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION[] WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRPr REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer tinesPit PrivyY �r Sewage Disposal Field Cesspool/Seepage Pit _ Other 1 Property!Line Private Domestic Well Public Domestic Well INTENDED USE ) TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation = PLDOMESTIC/PRIVATE Cl DRILLED Dia, of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Sea! ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H.P. C PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ® State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth I Describe Material and Procedure i r I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County k 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 for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." 1 wil II for Grou s lion prior to grouting and a final Signed X Title: _ � Date: ,,2 29-90 (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I �,T1J Application Accepted By ba—JCI(,[.c !p - Date IwLeo Additional Comments: j. Phase Il Grout Inspection al �nspectionQ� Inspection By Date Inspection 2��Ia DateFee IS Due: ❑ ANNUALLY ❑ PER UNIT..,_,_❑ PER SITE ❑ EACH ❑ January 1 & edByJanury 31 ❑ July 1 8 Received By Juiy 31 I, REMIT BILLING REMITTANCE $ BASE EXPLANATION "'" AMOUNT DUE CHECKED , DATE �DATEREMITTED AMOUNT FEE - 1y. LESS PRORATION PLUS PENALTY OTHER n OTHER 'R63 7 Received by Dat 1 Receipt No, Permit No Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITJSERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,C_ 95201 - r.