SU0007123 - Laserfiche WebLink

Home Browse Search

FOR OFFICE USE: APPLICATION ' (For Non-Transferable, Revocable,Suspendable, . PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is � made in compliance with a Joaquin Coun Or 'nance o. 1862and the r es a d regulations of the San um o Health District. Exact Site Address ^ City/Town„_ d X6 Owner's Name Phone 9-81 -7 7 e� Address City c�U Contractor's Name olxney License If Business Phone f Contractor's Address Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL 13 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ RWELL EPLACEMENT❑CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER AI _ PUMP IN TAL,LATION DISTANCE TO NEAREST: Septic Tank D / ewer Lines 01 f aPitt Privy ,�l(,6�.(,Q, J Sewage Disposal Field 6 Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑rrr---,,,,,,!!!IINDUSTRIAL ❑ CABLE TOOL Dia.of Well Excavation ��`��`,,rVDOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing OMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done P DESTRUCTION OF WELL: Well Diameter Approximate Depth . --//�� t��/ 8�Oh Descr a Mater' I- d Froc ure- --- -- ---- - - -- - - 1 hereby certify that I have prepared this applicatio nd that the work will be done in ccordance wit ►`+i"'uw 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 for which this _ 1 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. Signed X Title: Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I /� Application Accepted By r' `� L�' '��" � Date - Additional Comments: .4 Phase 11 Grout Inspection /�, P e Final In eate Inspection By Date / I Inspection By ate � Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July 7 8 eceivetl By July 31 BILLING REMITTANCE $ REMIT BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER A/f OTHER cJ�� Yn Received by Date Receipt No. Permit No. Isstlance CAte Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1001 E.HAZELTON AVE.,P.O.8012009 STOCKTON,CA 95201