SU0012713 - Laserfiche WebLink

Home Browse Search

Applications w111 Ptl ��-- "- APPLICATION LFOROFFIC�E�USE_ 4t,�p `��, (For Non Transferable, Revocable, Suspendable) it PUMP&WELL _ ENVIRONMENTAL HEALTH PERMIT r WATER QUALITYework.hereapplication is COMPLETE IN TRIPLICATE) application is ibe hereby made to the San Joaquin Local Health NDoSt1B62 a dpermit the rules and regulattiions oftthle S n JoaquinlLocalcHealth TDistrict. -- nade in compliance with San Joaquin County Ordinance ,� �____ — — .Gty/Town wQ _ _xact Site Address_ �-�—'�,�--� -�-- ph'one Owner's Name — ~"` City 7k�Business Phone_—4a'= �� — — — Address _ — S� — — _ License — i Contractor's Name _ � —'_ Emergency Phoneti -= —No — — Contractor's Address��—� _ NO — -- — _ - is Certificate of Workman's Compensation insurance on FiV ❑With RECONDITION ESTRUCTION❑ TYPE OF WORK (CHECK): NEW WELL❑ '—DEEPS. } WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR REPLACEMENT❑ -- Sewer Lin Pit Privy —— — — — ._____..------ DISTANCE TO NEAREST: Septic Tank _—— — — i nes Cesspool/Seepage-Pit _ --- — — Other-- - - — — Sewage Disposal Field public Domestic Well - — ——— — — Property Line— — Private Domestic Well_^ — ' TYPE OF WELL — —— — — INTENDED USE Dia. of Well Excavation. — — --- — — INDUSTRIAL ❑ CABLE TOOL —— 11 DRILLED Dia. of Well Casing ❑ DOMESTIC/PRIVATE ❑ DRIVEN Gauge of Casing`'— — ——-- — — DOMESTIC/PUBLIC - J GRAVEL PACK Depth of Grout Seal — — ---— — J — -- IRRIGATION , ❑ ROTARY Type of Grout ❑ CATHODIC PROTECTION Other Information— — — — — — -- ❑ DISPOSAL OTHER Surface Seal lnstall d By: — — — — — — ❑ GEOPHYSICALxA.. — — — — Contractor— �_ ��— — H.P. PUMP INSTALLATION: '-- — — -- .� Type of Pump — ——— — — — —_ PUMP REPLACEMENT: C3 state Work Done State Work Done r� Q ---— PUMP REPAIR: —__ Approximate Depth — — — `IC DESTRUCTION OF WELL: Well Diameter_ — — — -- — — — — — 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 o- Local Health District. "I certify for which this < Home owner or licensed agent's signaturecertifies e following to becomesubject to workman's compensation laws of Cal formai" is issued, I shall not employ any person s such manner Contractor's hiring or sub-contracting signature ret certifies the volloo ing:"I certify thation laws i the pCalifrmamance of the work for which this permit is issued, I shall employ persons 1 1 NI call for a Grout Inspection prio t :gi6d inq and incl inspection. Date: Signed G � (Draw Plot Ian on Reverse Side) FOR DEPARTMENT USE ONLY PHASE 1 P — — — —-- Date__ Application Accepted By = �l -tom— — — �_-- — Additional Comments: —. hase III Final In ection Phase 11 Grout Inspection w � •moi �l7ate-r— — Date_� — Inspection By• �--�=`/IVY/ Inspection By — , �„I t &Received By J iy 3' + Rece+ved By January 31 ❑ Y PER UNIT ❑ PER SITE ❑ EACH. ❑ January'. S — REMIT Fee Is Due:❑ ANNUALLY _❑T —"— - REMIITANC $ AMOUNT DUE CHECKED I BILLING DATE REMITTED AMOUNT BASE EXPLANATION DAZE I _ - - I -- �- 4- FEE — LESS — PRORATION PLUS - PENALrY OTHER OTHFR �I su� Date - Mailed Delivered RecerPe No Permit No STOCKTON,CA 95201 F ,�v 00 by Date 1601 E.HAZELTON AVE..P.O.909 2009 APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES