Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendpble) I PUMP &WELL -� <br /> ENVIRONMENTAL HEALTH PERMIT ( r <br /> (COMPLETE IN TRIPLICATE) `.WATER QUALITY r t w) E t .-<. <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or_installthe work herein described.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 3112 Loomis Road'. City/Town Stockton <br /> Owner's Name Church .of i'Jesus Christ 'Latter=Day Saints Phone <br /> Address 50 East -North }Temple Street city Salt Lake Cit , Utah <br /> Contractor's Name Clark Well & *Eq ul merit ' License#1715,60 . Busin ss Phone 462-5597 <br /> Contractor's Address 2024 E�-Cha.rter- Way.. - - Emergency'Phone N/A, � <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELD DEEPEN❑ RECONDITION❑ DESTRUCTION❑WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 1 PUMP INSTALLATION ❑ PUMP REPAIR 11 >i <br /> REPLACEMENT❑ ti i <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 /> r, INTENDED USE n, TYPE OF WELL, e <br /> w ❑-ANDUSTRIAL­ €' ❑-CABLE T0OL Dia: of-Well-Excavation - - <br /> 55 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 6 $,r <br /> 1:1DOMESTIC/PUBLIC i, ❑ DRIVEN Gauge of Casing #12 <br /> 13 IRRIGATION N ❑ GRAVEL PACK Depth of Grout Seal _i �0 it { <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout Cement <br /> j <br /> ❑ DISPOSAL ' Cl ;`OTHER Other Information - <br /> ❑ GEOPHYSICAL u <br /> I, Surface Seal Installed'By: <br /> PUMP INSTALLATION: N Contractor L "� <br /> Type of Pump —H.P.. �- <br /> PUMP REPLACEMENT: I - •❑ State Work Done t. I <br /> PUMP REPAIR: ❑ State Work D e - <br /> DESTRUCTION OF WELL: j9 Well Diameter _ Approximate Depth ( I' <br /> jE Describe Material and.Procedure <br /> ' ! �1► I <br /> 1 � v <br /> I hereby certify that I !have prepared this application and that thework will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin_LocAI Health-:District. <br /> 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 signaty u�re certifies the'follo`wingi 'l certify'that in the performance-of the work for which this <br /> per t is issued, I shall employ persons subject to workman's compensation laWS o-f`Calif0Tffia."""""-' <br /> h t <br /> I WIkJPlI for a ra i In ion pri r to grouting and a final inspection. <br /> Signed X r ' `" '� ;.Title: Sec-Tres Dale: Apr i 1 8 , 19 81 <br /> µ ' ,t;..(b,raw,Plot Plan on Reverse Side) <br /> 1 <br /> ( FOR DEPARTMENT USE ONLY <br /> PHASE I _ -.!"`u ►•I_ (L l <br /> Application Accepted By--�- .Da�e ....— <br /> Additional Comments: <br /> a <br /> Phas <br /> PIII,FaI Inspection <br /> ae II Grout inspection - <br /> Inspection By. Date 74 Inspection By <br /> Fee Is Due: 13ANNUALLY i ❑ PER UNIT ❑ PER SITE ❑ EACH C1January 1 &Received By January 31 © July 1 &Received By July 31 <br /> REMIT <br /> I BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED <br /> I AMOUNT <br /> FEE �� dy L3 <br /> LESS I <br /> PRORATION q <br /> PLUS �Y <br /> PENALTY y <br /> ,y OTHER <br /> OTHER <br /> Ll 'S g <br /> + Received by Date Receipt No. Permit No. I suance Date Mailed Delivered - <br /> APPLICANT—RETURN ALL CO <br /> PIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />