Laserfiche WebLink
Ih ApplicationsWill Be Processed When Submitted Properly Compl Bele To Sign T;�I11 ` <br /> plication. <br /> FQR OFFICE USE: APPLICATION d"I., <br /> (For Non-Transferable, Revocable, Sus ble)09ENVIRONMENTAL HEALTH PERMIT � � P&WEIL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY SP�` EP�� ty�sp, <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or inst�llthe work herein descri d.This application is <br /> made in compliance w n}Joaquin County Ordinance No.1862 and the rules and regulations of the San Joaquin Local ealth District. <br /> exact Site Address b 72 Waterloo Rd. <br /> City/Town Stockton <br /> Own II s Name Maurice Vieira <br /> Phone <br /> Address same City <br /> Contractor's Name City <br /> Water Systems License# 267696 Business Phone 931-3210 <br /> Cont actor's Address 4243 Cherryland Ave. Emergency Phone same i <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No J <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN C1RECONDITION❑ DESTRUCTION❑ <br /> WELLICHLORINATION ❑ WELL ABANDONMENT E] OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> � I <br /> Sewage Disposal Field Cesspool/Seepage Pit Other g <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INpUSTRIAL 11 CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRI.VATE ❑ DRILLED Dia. of Well Casing <br /> ❑ COMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CAITHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL 4 ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL f <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Moorman' s Water Systems t <br /> i Type of Pump ° H.P. 3 { <br /> PUMP REPLACEMENT: ❑ State Work Done R <br /> PUMPI REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximgtj�D�epth <br /> Describe Material and Procedure de If <br /> i <br /> i I 1 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." t <br /> ' Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will all for a Grout Inspection prior to grouting and a final inspection. <br /> Signs.d X � 6r Title: � � Date: i. <br /> (Draw Plot Plan on Reverse Side) <br /> �IFOR DEPARTMENT USE ONLY <br /> I <br /> PHASE ! �� <br /> 'Application Accepted By ( QQ <br /> Date <br /> 'Additional Comments: , <br /> Phase II Grout Inspection �SFinal sptianInspection By. Date Inspection BJute gy 4r, 1 <br /> s <br /> i <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 &Received By Juiy 31 <br /> BILLING REMITTANCE $ REMIT , <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE ov a <br /> .1 <br /> LESS <br /> PRORATION <br /> PLUS ' <br /> PENALTY <br /> OTHER l <br /> OTHER <br /> 0Received by Date - Receipt No. Permit No. Issuance ate Mailed Delivered <br /> ,!APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,.P.D.Box 2009 STOCKTON,CA 95201 <br /> c <br />