Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
;'"Apptications Will Be Processed When Submitted Properly Co t % n eZation. <br /> FQgOFFI'2E USE-- APPLICATIO(For Non-Transferable, Revocabl pendable) <br /> ENVIRONMENTAL HEALTH PERW-0 - 11982U1G' JELL <br /> (COMPLETE IN TRIPLICATE) T WATER QUALITY f <br /> Applyation is hereby made to theSan Joaquin Local Health District fora permit toconstruo WIM-Ppt kescribed.This application is <br /> Fain compliance with San Joaquin County Ordinance No. 1862 and the rules and regu�I4e� I Local Health District.Site Address 66 A City/Townr's Name �Git Phone <br /> Address ;ISO I�31 ar - - City M©tl^�t�rN r✓iE�cJ <br /> Contractor's Name ,DikV Ai 't+ a License#35'0'L5 17 Business Phone <br /> Contractor's Address _1�+ 3 AJ6 b/�. Emergency Phone `/.�J 9ZV6 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes Xe_ No <br /> TYPE OF WORK (CHECK: NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION CD <br /> '1NELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR RL <br /> ,�.REPLACEMENT�'� <br /> ,.DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> 1 Sewage Disposal Field Cesspool/Seepage Pit Other ° <br /> -' Property Line -_ Private Domestic Well Public Domestic Well <br /> A,. INTENDED USE TYPE OF WELL <br /> INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation - M <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing I ' <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing t <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seat <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout t <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed B&, <br /> COLI <br /> ' PUMP INSTALLATION: Contractor s 1/ M4,e_k I A-1,=t µ,c' -� <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done_ P(-4-.Z F_&iLA-AP f=74Z) C*t_.l 5� <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure ' <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local 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 signature certifies the following:"I certify that in the performance of the work torwhich this <br /> permit is issued, I shall emplo ons subject to workman's compensation laws of California." `n <br /> ' c or a Gr t n ecT n pr' r to grouting and a final ' <br /> inspec on. � <br /> 5i�ned X Title: 'r. Date: <br /> !� (Draw_Plot Planpon Re erse Sid <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> fh— <br /> t <br /> Application Accepted By Date <br /> Additional Comments: _ .. <br /> Phase II Grout Inspection Phase 11-Final Inspection_ <br /> Inspection By Date Inspection By ?�' QZ-WI--Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMETTANCE .$ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE L� <br /> LESS <br /> PRORATION t <br /> PLUS <br />' - PENALTY <br /> OTHER <br /> 'OTHER01 <br /> Received by Date Receipt No Permit No. Isstlancb Date - Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 ,+ <br />