SU0014620 - Laserfiche WebLink

Home Browse Search

Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Appl is on. FOR OFFICE USE: APPLICATION ldt z / 7 Non-Transferable, Revocable;Suspendable) O PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made t0 the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is made in compliance with San Jpaquin County Ordinance No. 1862 and the,rules and regulations of the San Joaquin Local Health,District. Exact Site Address - �~y,-- -?�>-1Le� .a:r Citylfown i2e-" - - - - - Owner's Name/ ',+ f �- `�- �'ttS� r� Phone $�1�6 ' L �i �Z _ Address --4 __-ILI:z n-t `�— ~ ��S.��1I City Contractor's Name / License^-v-1J.J�—)4_ Business Phone �}-3J''al-�) Contractor's Address -�. J{- t/j �'-� 7 --r- Emergency Phone'/ ^` Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTIO,NN0 WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION v� PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy k Sewage Disposal Field Cesspool/Seepage Pit Other Y Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ IN TRIAL ❑ CABLE TOOL Dia. of Well Excavation ID-DOMESTIC/PRIVATE ❑ DRILLED _ Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL d OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: -� PUMP INSTALLATION: contractor 4,�(i �.%�' P Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done — PUMP REPAIR:' - ❑,State Work Done DESTRUCTION OF WELL: V1611 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 certify that 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 forwhich this permit is issued, I shall employ persons subject to workman's compensation laws of California." I will C W r a Grout Inspection prior to grouting and a final inspection. Signed X dy,l ` ' _ Title: L'C�-VL41, ` ;(Draw Plot Pla6 on Reverse Side): �FOR DEPARTMENT USE ONLY PHASE ✓L7^/ Application Accepted By-y`--`' C iGL4Lr�_ Date /. Additional Comments: Phase 11 Grout Inspection ase III FI Inspection Inspection By Date' Inspection By Date 1114 Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 0 PER SITE, ❑ EACH ❑ January 1 d Received By January 31 ❑ July 1 d Received By July 31 REMIT BILLING REMITTANCE S BASE EXPLANATION DATE DATE REPAITTED AMgUNT DUE CHECKED _FEE LESS r PRORATION PLUS r - PENALTY OTHER OTHER Received 9y Date Receipt No. Permit No.. lu Innee D e Mailetl_ Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201