SU0004651 - Laserfiche WebLink

Home Browse Search

Applications will rte ProcesseswnensuomtneaPropertycompletes. nosure tosign tneApplication. FOR OFFICE USE: APPLICATION V,For Non-Transferable,Revocable,Suspendablt� PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install thework herein described.This application is made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Lo�aw-1 Health District. Exact Site Address 'µnn �A[ .�01) S. City/Town Owner's Name /� //� VCLL'L!C �a+/A �� l' Phone 'L4'6 6l4 s2 Address37 f:f AAts.n City Contractor's Name S-14*L, � // 1 Al License# /fbl -'t'7Business Phone SL{]. - W 74 Contractor's Address OW V A. _a, d aill dP,/, Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes x No I TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ n WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR Jl REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy _ Sewage Disposal Field 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 ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/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. 1 PUMP REPLACEMENT: ❑ State Work Done '0 PUMP REPAIR: )19 State Work Done '+' 2-195 `C-/&V 7"de k' /111f y 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. 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 forwhich this permit is issued, I shall employ persons subject to workman's compensation laws of California." 1 will call for a Grout Inspee p or uting an final Inspection. Signed X L Title: .r Date: a' (Draw PI(V Plan on Reverse Side) FOP DEPARTMENT USE ONLY PHASE I Application Accepted By Date Additional Comments: Phase 11 Grout Inspection h Iinnall Inspection�_/� -0Inspection By Date Inspection By 10V01- iV f -_ Date 7 Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January$1 ❑ July 1 8 Received By 1 BILLING REMITTANCE E REMIT BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED. AMOUNT FEE a LESS ) PRORATION 3A , l // fLr f*� PLUS VA 6VT Act l27 r 4 PENALTY r. f'Ll )-A cl C e, Jv f.f,-A 1 OTHER Wt N Ljl�w .M.-SN' i {"y cf 12 t, +,rs.n,../ OTHER Cl2 F111 -- - - --- `7�►-.Jk � _ >l-11� -- - -- Received by Date Receipt No, .Permu No. Issuance Date Mal!ed Dell red APPLICANt-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES -1601 E.HAZELTON AVE.,P.O.9az 2009 "STOCKTON,glrgw