SR0084224_SSNL - Laserfiche WebLink

Home Browse Search

1' Ir Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign i ne Appncanvn. APPLICATION APPL ' FOR OFFICE USE: _ (For Non -Transferable, Revocable, Suspendable) PUMP &WELL ❑ DRILLED Dia. of We[I Casing ........ ENVIRONMENTAL HEALTH PERMIT + )MPLETE IN TRIPLICATE) WATER QUALITY, pplication is hereby made to the San Joaquin Local Health District for a permitto construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 1882 and th rules and regulations of the San qui Local Health District. ;Type of Grout Exact Site Address �-3.__4�• _ __Ea�L__ City/Town _ ---- -- Y Other Information Phone-- � rte; Owner's Name ---- - AMOUNT — oZj Address �'•drlEsl-- License #1 business Phone_-�'1 _City Contractor's Name Contractor's Address �� Emergency PhoneIs Certificate Certificate of Workman's Compensation Insurance on File ith SJLHO? YesNo NEW WELL DEEPEN ❑ RECONDITION 11 DESTRUCTION TYPE OF WORK (CHECK): ,❑/' WELL CHLORINATION 13. WELL ABANDONMENT 11 OTHER 11 PUMP INSTALLATION PUMP iiEPAIR❑ 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 ❑1 INSTRIAL U'DOMESTIC/PRIVATE ❑ DOMESTIC/PUBLIC ❑ IRRIGATION ❑ CATHODIC PROTECTION ❑ DISPOSAL ❑ GEOPHYSICAL PUMP INSTALLATION: PUMP REPLACEMENT: `UMP REPAIR: .ESTRUCTION OF WELL: TYPE OF WELL u ren • �" • • - — ❑ CABLE TOOL Dia. of Well Excavation ❑ DRILLED Dia. of We[I Casing ........ ❑ DRIVEN Gauge of Casing ❑ GRAVEL PACK (Depth of Grout Seal El ROTARY ROTARY ;Type of Grout ❑ OTHER Other Information surface Seal Installed By: Contractor_ "— Type of Pump i��- - )l�"-- H.P. — �' ❑ State Work Done. - - - ❑ State Work Done _ 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 Joaquin County ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: ''I certify4hat in the performance of the work for which this permit is issued. I shall not employ any person in such manner as to become subject to workman's compensation laws of California.": Contractor's hiring or sub -contracting signature certifies the following: "I certify that in -the performance of the work forwhlch this permit is issued, I shall employ persons subject to workman's compensation laws bf California." 3 ca a Grout' pec 10 prior to grouting and a final inspection. —� Sig Title: ZW q! Date�=�- . (Draw Plot Plan on Reverse Side) I �" fi �a FOR DEPARTMENT USE ONLY PHASE Application Accepted By — Additional Comments:--- 11 omments: s II Grout Inspection Inspection By �- -- Date _—AN�V -- Inspection By Date. Finallnspection S.Date..11 r_1 i u Q--1 Rv .lanuary 31 ❑ )u' -y 1 & Receiveo By July 31 -ee IS Due: U ANNUALLY u ren • �" • • - — -REMIT BILLINGUNT DJE CHECKED BAST=. EXPLANATION DATE - -- AMOUNT — =EE PRORATION =ANCFAIAC PLUSPENALTYU1HEROTHER ww Rece+ver, by Date APPLICANT—RETURN ALL COPIES TO, Race pt No. Permit No Is ante ate - "Mailed Delivered ENVIRONMENTAL HEALTH PERMITlSERYIGES 1601 E. HAZELTON AVE., P.O" Bos 2009 STOCKTON, CA -95201