SU0014620 - Laserfiche WebLink

Home Browse Search

Applications Will IBe Processed When Submitted Properly Completed. Be Sure To Sign The Application. I FOR OF CE USE: APPLICATION Lo� a � or Non-Transferable, Revocable, SuspendablL PUMP&WELL i ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health Districtfor a permit toconstruct and/brinstall the work herein described.This application is J/ made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. 1 Exact Site Address3 0f1,- �� City/Town ,may/ Owner's Name aidi�JJyL�lwn.r��a"?r t � Phone (0 - O 1-I- Address la " � City_24CC ti- Contractor's Name —,ji1,Q• � �� G�A�� License#33n47, Business Phone Contractor's Add resst2_,.. �-�/ 5� Emergency Phone _ Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X• No TYPE OF WORK (CHECK): • NEW WELL❑, DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION 0 WELL ABANDONMENT ❑' OTHER ❑ PUMP INSTALLATION �K PUMP REPAIR❑ REPLACEMENT - 1 DISTANCE TO NEAREST: Se Ptic Tank Sewer Lines .Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line � Private Domestic Well Public Domestic Well INTENDED USE TYPE OF YELL r❑-,�INDUSTRIAL ❑ CABLE TOOL � Dia. of Well Excavation IZDOMESTIC/PRIVATE 0 DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing c� ❑ IRRIGATION P GRAVEL PACK Depth of Grout Seal - n ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL 0 OTHER Other Information - ❑ GEOPHYSICAL - Surface Seal Installed By: PUMP INSTALLATION: Contractor P1221, �- Type of Pump 1 !- H.P. ( PUMP REPLACEMEN : ❑ State Work Done t �� PUMP REPAIR: I r Stgte Work Done — t_ I f DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure ' I hereby certify that I have prepared this application and thatthe work will be done in accordance withl an Joaquin County ordinance, state laws, and rules and regulations of the San Joaquin Local Health District. i Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I�shall not employ airy person in,such manner as to become subject td workman's compensation laws of California.:' Contractor's hiring or sub-contracting signature certifies the following:"1 certify that in the performance Of the work forwhich this permit is issued, I shall employ parsons subject to workman's compensation laws of California." I will ILfor a,Grout Inspection prior to grouting and a final Inspection.: Signed .rL. ,'" Title: 2T=91 - i Date: //- • (Draw Plot Play}on Reverse Side) FOR DEPARTMENT USE ONLY PHASE + IV-2:Y21 / 2 ri Application Accepted By I Date I 7-1 Additional Comments: _ . Phase II Grout Inspection 1 - Phase III Final Inspecti IT Inspection Bye_ Date Inspection By R. Fee Is Due: ❑ ANNUALLY ❑ PER UNIT , ❑ PER SITE ❑ EACH I, ❑ January 1 8 Received By J ry 31 ❑ July 1 8 Received By July 31 BILLING REMITTANCE s REMIT BASE t EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE sil- 1 LESS - f 4 - - PRORATION PLUS PENALTY ', A ` OTHER OTHER 3 Received by Dale Receipt No Perms No. la caste ate Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201