SU0004962 - Laserfiche WebLink

Home Browse Search

A fidatimis Will Be Process d WflTn Submitted Properly Completed. Be Sure To Sign The Application. �` .r� APPLICATION FOR OFFICE USE: t C.E? 1 0 J For No, -Transferable, Revocable, Suspendable) PUMP&WELL .01E*�ONMENTAL HEALTH PERMIT 014 �� r}IS WATERUALITY 5 L!O D p low (COMPLETE IN TRIPLICATE) 4-ALA Q 9 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 an Jo in Co t Ordinance No. 1862 and the rules and regulations of the San _ uln�Lp c�al HQalth District. Exact Site Address q §•y rL�l�� r✓� g _ City/Town t-�'ii5 Z Owner's Name A Phone `'��v � �� Address In � nn^ City AJ Contractor's Name . D ru� License ISG"/ v Business PhoneA Contractor's Address •a ^ Emergency PhoneLn Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes IVIA� No j TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION I? PUMP REPAIR 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 nnSurface Seal Installed By: 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 I hereby certify that I have prepared this application and that the work will be done in accordance with San JoaquilCounty ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owneror licensed agent's signature certifies the following:"I certify that in the performance of thework forwhich this issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of Ca 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 empl y persons subject to workman's compensation laws of California." I wi all for Grout Ins io rior to grouting and a final inspect' _ Signed X Title: Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I v (1 JVO�- ( Application Accepted By, � lJla Date `v Additional Comments: Phase II Grout Inspection Phase III Final Inspection Inspection By \A Date__ Inspection By Date\_0 Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS PRORATION - PLUS PENALTY — OTHER OTHER 2- Received y Dat Receipt No. Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 -STOCKTON,CA 95201