SU0006542 - Laserfiche WebLink

Home Browse Search

FOR OFFICE USE: - APPLICATION 'For Non-Transferable, Revocable, Suspendablr.../ PUMP&WELL 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 w 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 5105 Lovely Rd .-between Old Arry 50 & Bi>cify/fidrb, north side, Tracey Owner's Name Joe Cuesta Phone 83-5-0441 Address 5105 Lovely Rd . city Tra cry Contractor's Name Henning s Bros. Licenses 29081 3 Business Phone^545-1 185 Contractor's Address3 2 Pelandale ll Mode Ca a Emergency Phone 545-0291 Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No iO TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank 11 1 Sewer Lines Pit Privy Sewage Disposal Field 1111+ Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia.of Well Excavation 13 n sad EI DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 81t PVC VN ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 160 WALL IRRIGATION GRAVEL PACK Depth of Grout Seal02-1 _ — - ❑ CATHODIC PROTECTION ROTARY Type of Grout BENTONITE ❑ DISPOSAL ❑ OTHER Other Information SLAB—BY OWNER r ❑ GEOPHYSICAL Surface Seal Installed By: DRILLER PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure /7 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 forwhich 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 will call for a Grout Inspection prior to grouting and a final inspection. Signed X Title: �/�-e�. Date: Op'a�/–/-7 9 (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I Application Accepted By Date Additional Comments: Phase 11 Grout Inspection Phase III Final Inspection Inspection Byt( •Inspection By ate M EA Fee IS Due: ❑ ANNUALLY 11 PER UNIT PER SITE C ❑ January i&Received By January 31 ❑ July 1 &Received By July 31 REMIT BILLING REMITTANCE BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER i -711 # —q 7 Received by Date Receipt No. Permit No. Issuance DateMailed livered •�r/ '� APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.HAZELTOM AVE., .O.BOX 900S STOCKTON, A 9fN1�