82-210 - Laserfiche WebLink

Home Browse Search

Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFIC f{5'JSE. APPLICATION r - (For Non-Transferable, Revocable,'Suspendable) PUMP&WELL J ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY 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 Co my Ordinance No.11862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address— ro,cl�"i 7 o2 eye City/To �c.'� wn 40 01 Owner's Name C 9�1 Phone's Address Z" 76 / �),�,�ii�/A �"`�: ''� Y City "T G.cil•' Contractor's Name I'lrcLicense#3V Business Phone Contractor's Address �u 13h)e � i �G�/c>�D. / '�C= Emergency Phone Is Certificate of Workman's Compensation_Insurance on File With S_JLHD? Yes No TYPE OF WORK (CHECK) NEW WELLS DEEPEN❑ RECONDITION❑ DESTRUCTION❑ t WELL CHLORINATION ❑ WELL ABANDONMENT ❑- OTHER ❑ PUMP INSTALLATION Z PUMP REPAIR❑ J REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tanker Sewer Lines Pit Privy Sewage Disposal Field /ao Cesspool/Seepage-Pit Other Property Line Private Domestic.Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well'Excavation ❑ DOMESTIC/PRIVATE 11DRILLED Dia:of Well Casing j ,yDOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing /-Z ❑ IRRIGATION .GRAVEL PACK Depth of Grout Seal S,2 ❑ CATHODIC PROTECTION ``ROTARY Type of Grout - Sc ❑ DISPOSAL _ ❑ OTHER - - Other Information '❑ GEOPHYSICAL ` Surface Seal Installed By: PUMP INSTALLATION: Contractor /7— l�/ 0�5 Type of Pump 0a o v S' H.P._ - PUMP REPLACEMENT: ' ❑ State Work Done PUMP REPAIR: ❑ State Work Done . DESTRUCTION OF WELL: Well Diameter Approximate Depth { Describe Material and Procedure i . i 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. { Home owner 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." I will call for a Grout Inspection prior to grouting and a final inspection. Li Signed X �� .ezy�S Title:_ ��✓ � Date: (Draw Plot Plan on Reverse Side) t E FOR DEPARTMENT USE ONLY PHASEI Application Accepted By Date �� Additional Comments: z Pha a II Grout Inspection Ph4pe III Final Insp ctlon i frx Inspection Bye �7ate "�" Inspection ey 1 ate { i c� / a Fee Is Due: ❑ ANNUALLY 0-PER UNIT ❑ PER SITE' ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BILLING REMITTANCE $ BASE I 'EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED c AMOUNT 1 FEE. 06 lr "LESS PRORATION PLUS PENALTY OTHER I OTHER Received by Date Receipt No. Permit No Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 1