83-298 - Laserfiche WebLink

Home Browse Search

Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION .F (For Non-Transferable',''Revocable;Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIS W (COMPLETE IN TRIPLICATE) 16-793 WATER QUALITY ' Application isttereby made to the San Joaquin Local Health District fora perfrlit toco'n;truct'and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No. 1862 and the rules and'rgguI tions of the San Joaquin Local Health District. Exact Site Address 1 .jCity/Town .O d �G�`�s Owner's�NBme Phone, — �7r - a. Address Cr-t4j AO/L." .,, City Contractor's Name License#'I" Y/3 Business P.hone'? r �f� '�Y: Contractor's Address � � -"'Emergency Phones Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_ X _ No TYRE OF'WORK:((jHECK): NEW WELL-""`DEEPEN ❑;--�;RECONDITION EY DESTRUCTION❑ WELL CHLORINATION 0 - WELL ABANDONMENT,❑ _ OTHER ❑ ...PUMP_INSTALLATION'P PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic TankSewer Lines F Pit Privy # Sewage Disposal Field / Q _ -Cesspool/$eepage.Pit Other Property Line Private Domestic Well 1 Public Domestic Well INTENDED USE TYPE OF WELL �� cas ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing n/ +IC, DOMESTIC/PUBLIC 13 DRIVEN Gauge of Casing E] IRRIGATION GRAVEL PACK . Depth of Grout Seal ♦ _ j ❑ CATHODIC PROTECTION ROTARY Type of Grout D DISPOSAL '❑ OTHER r Other Information l ❑ GEOPHYSICALq X75 Surface Seal Installed By,.' { PUMP INSTALLATION: +% Contractor Type of Pump. H.P. i. PUMP-REPLACEMENT: ❑ State Work Done i PUMP REPAIR: ❑ State Work pone c DESTRUCTION OF"WELL: Well Diameter Approximate Depth Describe Material and Procedure rt ` l 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 certifiies the following:"I certify that in the performance of the work forwhich this permit t L ;-is issued, I shall not.employ any pefson 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 f' 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. _ i t Signed X, Title: Date: _ ( aw Plot Plan on Reve se Side) �� FOR DEPARTMENT USE,ONLY f PHASE I ' Application Accepted By `x �� W ' Date 1 Additional Comme g t fns ectionase IN Fipq Inspection r Inspection By Date inspection By Fee Is Due:-❑ A uALLY ❑ PER UNIT -❑ PER SITE 1 0-EACH' ❑-January 1 &-Received By January 31 ❑ July 1 &',Received Sy July 31 REMIT i. BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT - FEE L] 4 LESS PRORATION 1 ,. PLUS - PENALTY : OTHER OTHER MV= U129 U _ ,Received b Date eceipi_No:. - Permit No... ,. IssIliance Dae Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201