SU0001312 - Laserfiche WebLink

Home Browse Search

-vii-aliV113 Yviii ae rrocessea when SubmittedProperly Complete�di_.!�e Sure To Sign The Applic�t�t:jrt(. Fat3 oFFtcE USE: APPLICATION �� d I;s or Non-Transferable, Revocable, Suspendable ',:3 3—/o ENVIRONMENTAL HEALTH PERU-1 ��_f. }�,? LOCAL &WELL (COMPLETE IN TRIPLICATE) WATER QUALITY HEA" 1i DISTRICT 42-G2 V5 r Application is hereby madetotho San Joaquin Local Health Districtfora permitto constructand/or install thework herein describ #sapplication is j 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 City/Town Lodi. Can 95240CA CA Owner's Name Phone 369-9 Q W d Address City Lodi 1 i Contractor's Name License#X52 Business Phone 334-9110 Contractor's Address Emergency Phone 369-0982 Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 0--91]1pp O 9S~— j TYPE OF WORK (CHECK): NEW WELL® DEEPEN ❑ RECONDITION❑ DESTRU CTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank 65 - Sewer Lines Pit Privy -� Sewage Disposal Field_ ---- Cesspool/Seepage Pit 125 f t Other Property Line 100+ Private Domestic Well 8o ft public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIALt7 1 CABLE TOOL Dia. of Well Excavation-12 Ito 0 tt3 T1t1 , DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing R Inch -3 ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 10 ga . ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 50 f t . ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout 9 Sk grt . ❑ DISPOSAL ❑ OTHER Other Information —rte ❑ GEOPHYSICAL Surface Seal Installed By: 1� PUMP INSTALJ.ATION: Contractor � Type of Pump H.P. PUMP REPLACEMENT: State Work Done PUMP.REPAIII ❑ State Work Done 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-contracting signature certifies the following:"I certify that in the performance of the work forwhich this ' permit is issued, I shall employ persons subject to workman's compensation laws of California." I w I �,Out �pecfinor to grouting and a final inspection. 1 Signed X Title: Contractor _ Date: Nov. 4, 1982 (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY f PHASE I , q Applicatiorf Accepted �* bate Additional Comments: f j� Phas II rout Inspec ion Phase III Final Inspection � t:4,1 Inspection By to �. --_ Inspection By Date sr-'113-t 3 Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Receive By Janu%ry 31 ❑ July 1 &Received By Juiy 31 y-- REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE q LESS PRORATION PLUS PENALTY OTHER i OTHER I � 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.Bo=20119 STOCKTON,CA 95201