Laserfiche WebLink
Appucauonswill BeProcessedWhen Submitted Properly Completed. B�e To Sign The Appllcation.�„�'"` + ~ <br /> FOR OFFICE ust:: APPLICATION AUG2 9 1979 <br /> (For Non-Transferable, Revocable, Suspendable) p & 6 <br /> ENVIRONMENTAL HEALTH PERMIT SAN JOAQUIN L�P4LwE�l_ � <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY HEALTH DISTRICT - <br /> Application is hereby madetotheSan Joaquin Local Hoalth District for a permit to construct and/or install the work her��escribeedd.This application is ) <br /> made in compliance with San_Joaquin-.0 unty.Ordinance.No. 1862 and the r es and regulations of the San Joaquin i-ocal Health District. <br /> Exact Site Add r�e¢ss� 5 Q,-14'. —CA 1 � q Q/ �Ly y City/Town f Q 1 <br /> Owner's Name 7/ V r i Phone _3f-9 - ; t � <br /> Address City <br /> Contractor's Name v+ License#12? Business Phone "7 Sf' ,7— ( ,��•( 7 <br /> Contractor's Addlrk �t Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL®-' DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ V <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank C; Sewer Lines .© Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other +' <br /> Property Line Private Domestic Well Public Domestic Well �( <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL <br /> 13--CABLE TOOL Dia. of Well Excavation , ; <br /> ❑"DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing d <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK. Depth of Grout Seal ' S4 , <br /> ❑ CATHODIC PROTECTION ❑ ROTARY <br /> Type of Grout c t <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor - } <br /> Type of Pump H.P. ". <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> l <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, I shall not employ any,person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ-persons-subject-toyworkman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. . <br /> Signed XC S ._ .... ., W. -,-� <br /> ._ � Title: Y` Date: 'Z`Z � <br /> (Draw Plot Plan on Reverse Side) �# <br /> OR PARTMEN US ONLY f <br /> PHASE I <br /> Application Accepted By 4� C,; Date <br /> Additional Comments: J <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By�l3Date ? Inspection By [n �..- DateOT <br /> ��4 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT U PER SITE ❑'EACH ❑ January 1 &Received 8y January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT e <br /> BASE EXPLANATION AMOUNT DUE C <br /> DATE DATE REMITTED CHECKED <br /> FEE <br /> LESS = !� <br /> PRORATION <br /> PLUS <br /> PENALTY - y <br /> OTHER <br /> OTHER <br /> 47 1-R r <br /> Received by ate Receipt No. I - Permit No. lissuarfice Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95 <br />