SR0083315_SSNL - Laserfiche WebLink

Home Browse Search

at ns Vll�lj e r Submitted Properly Completed.Be Sore To Sign The Application. FOR_OFIFICE usE: TJ � '� `� � APPLICATION _ (PorJrJ ransterabie,Revocable,Suspendable) PUMP&WELL 2ENVIRONMENTAL HEALTH PERMIT ,COMPLETE IN TRIPLICA� .! v1 a I WATER QUAUTY Application is hereby made to �S).,o_ Distrlctforapermittoconstruct and/or Install the work herein described.This apphcationis made in compliance with t No. 1862 and dations,of the San JAq o 1 eal District. Exact Site Address _ t` » ._ __._. _ — �.' —..— _City/Town - I Owner's Nair/ 'L . Phone ._........._ Address t!? City-......_.. _ _. __... Contractor's Name �- ' c 8usifieas h ;_ __:..: ) Contractor's Address 'L'��_t_.�._'EtnerrgOncy Phone ,fir"' ----•—r-- is Certificate of Workman's Compensation Insurance on Pile With SJLHO? Yes ' No . t TYPE OF WORK (CHECK)' NEW WELL0 DEEPEN❑ RECONOITiON1 DESTRUCTION❑ C' WELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER © PUMP INSTALLATION M''' PUMP REPAIR© REPLACEMENT CJ '`i DISTANCE TO NEAREST: Septic Tank ti.. Sewer Lines Pit Privy Sewage Disposal Field- _ CIIASPOoi/Seepage Pit----Other Prpperty,Line _ ,Private Domestic Well.Y..,-_-Public Domestic Well INTENDED USE TYPE OF WELL 13 INDUSTRIAL 0 CABLE TOOL Dia.of Well Excavation .. - DOMESTIC/PRIVATE i ❑ DRILLED Dia. of Well Casing -- ❑ DOMESTIC/PUBLIC O DRIVEN Gauge of Casing . - ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seat -_ 0 CATHODIC PROTECTION ❑ ROTARY Type of Grout__......_ __- ..... ❑ DISPOSAL © OTHER _. � Other Information ❑ GEOPHYSICAL ,.,_„Surface l Installed By: � PUMP INSTALLATION: Contractor 'j 1._ ..__. O Type of Pump r- _� H.P. PUMP REPLACEMENT: , �#ate Work L7one -.........�._._._ -=- PUMP REPAIR: © State Work Done - ----. DESTRUCTION OF WELL: + We&Diameter_�_...�..._ Approximate Depth f Describe Material and Procedure__: __ _......_.. 1 ... ............. 1 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. Homeowner or licensed agent's signature certifiers the following:"I certify that In the performance of thework for which this permit s issued. I shaft n ploy any person in such manner as to t�ecome sub' to workman's compensation laws of California" Contractor'a h g or sub-contracting signature certifies the following:" -e y that in the performance of the work for which this , pe iss d, I sha I emplo rsi_sut ject to workman's cnmpe s tan laws of California." will r Inspectt priogrouti an a final in" n��Side) " >J Signed X _._....... - —.__....� Title: . sDate. �____... ' 1 (Draw Piot Pian n Reverse x FOR DEPARTMENT USE ONLY PHASE I Application Accepte y � Additional Comm nts: Phase 11 Grout Inspection aq'III Final Inspection inspection By Date __ _...._ inspection By Date -a x Fee Is Due:❑ ANNUALLY ❑'PER UNIT © PER SITZ ❑ EACH © January t 6 RscNyva By Jerwa,y J1 ❑July T it Received By July 31 . _ _ __....... REMIT BASE £xPLANATit3N BILLING REMITTANCE � AMOUNT DUE CHECKED BATE DATE FRMiTTED A.0UNT FEE' LIESS PRORATION PENNALTY x l OTHER } :• j OTHER ...........__ ._ ._.__....... Received by floe -Receipt No Permit No 1 C Ma,led Delivered APPLICANT--RSTU M/ALL COP=TO WWWONMBffAL 00ALTH PI:RMITISERVI"S 16011 IL HAMTON AYE..,P.O.tie.M09 STOCKTOK CA OSM