82-427 - Laserfiche WebLink

Home Browse Search

Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. �S1 k FOR OFFICE USE: APPLICATION . f (For Non-Transferable, Revocable,Suspendable) " unn lj WELL a ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALIT* Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address Rivers Meadows_ Ub-dLVlSlori3O_QC17 ldgety%Town Woodbridge Owner's Name Phone 334-0670 Address City Lodi . CA. Contractor's Name C1 ark We1 1 Rs Equilr]ment License# 3?1560 Business Phone 462-5597 I Contractor's Address 20 Emergency Phone NA Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No K �J TYPE OF WORK (CHECK): NEW WELL 13 DEEPEN 13 RECONDITION 13DESTRUCTION❑ W WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONS PUMP REPAIR❑ REPLACEMENT❑ # DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy I Sewage Disposal Field Cesspool/Seepage Pit Other Ir Property Line 2,5 Private Domestic Well Public Domestic Well 1 INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing Z'DOMESTIC/PUBLIC r.. ❑DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL 1.1 Surface Seal Installed By: Clark Well I PUMP INSTALLATION: Contractor Stowell EQuipment 1 Type of Pump T.-ilrbi n� H.P. 1 OO PUMP REPLACEMENT: 1❑ State Work Done PUMP REPAIR: ❑ State Work Done \1 DESTRUCTION OF WELL: Well Diameter &Approximate Depth 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. 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- ractin signature certifies the following:"I certify that in the performance of the work for which this permit is issued, 1 II plo e s subj to workman's compensation laws of California." 4 I c Ito r u s c 'n p for i g and a final inspection. Signed X Title: VP—C1,9.rk Well Dale: 17 Aug. 1982 # (Draw Plot Plan on Reverse Side) � f FOR DEPARTMENT USE ONLY t PHASE I Application Accepted By `� Data- Additional Comments: a Phase 11 Grout Inspection Phase Ill Final Ingpection Inspection By !n Date Inspection By Date { Fee Is Due, ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 r BILLING REMITTANCE $ REMIT " - BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT 4 FEE � LESS ° l PRORATION I I PLUS j. PENALTY t OTHER 4 OTHER. L��APIIICANT—RETURN by � Date � Receipt No. Permit Nc- Issuance Date Mailed �Delivered ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - .1601 E.HAZELTON AVE.,P.0;Box 2099 STOCKTON,CA 95201 .yam.