SU0014620 - Laserfiche WebLink

Home Browse Search

Applications Will Be.Processed When Submitted Properly Completed. Be Sure To Sign The Application. I_rI 4 ) FbR OFFICE USE: APPLICATION ice• 7 Non-Transferable,Refocable,Suspendable) PUMP&WELL r ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY 1--� Application is hereby made to theSan Joaquin Local Health District for a permit to construct and/orinstall the work herein described.This application is made in compliance with San Joaquin County`Ordinaa�n-ceeft. 1862 and t rules and regulations-of the San Joaquin Local Health District, Exact Site Address; �^'' "' "Q.� City/Town t cc�r�� . Owner's Name '`'�— y. Phone 13 4 ' S Address ,City Contractor's Name LicenseBusiness Phone Contractor's Address ,^� n Emergency Phone l Is Certificate of Workman'sCompensation Insurance on File With SJLHD? Yes No 06 TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER O ,PUMP INSTALLATION M�UMP REPAIR 13 J REPLACEMENT❑ ' T DISTANCE TO NEAREST: Septic Tank �_ Sewer Lanes L Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line ` Private Domestic Well Public Domestic Well J INTENDED USE TYPE OF W€LL ❑ llN�D4STRIAL ❑ CABLE TOOL Dia.of Well Excavation 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 0 OTHER Other Information ❑ GEOPHYSICALce SSurfaeal Ihstalled_ By: PUMP INSTALLATION: Contractor ' � -c5� Type of P_ump_ H.P. PUMP REPLACEMENT: ❑ state Work Done PUMP REPAIR: ❑ Stat, e Work Done (' DESTRUCTION OF WELL: Wet;Diamefer Approximate Depth q . Describe Material and Procedure r: I hereby certify that I have prepaj,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. - - Homeownerorlicensedagent's signaturecertifies the following:"I certifythat 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." -I Contractor's hiring or subcontracting signature certifies the following:"I certify that in the performance of the work for which this Permit is issued, I shall employ persons subject to workman's compensation laws of California." It or a Grout Inspe ion prior to grouting and a final.Inspection. Signed i y( a ' Title', �"t�'L—+ - , Date: '6 (Draw Plot Plan on Reverse Side) - FOR DEPARTMENT USE ONLY PHASEI - t Application Accepted By Date Additional Comments: Phase II Grout Irlspectign i a>fo III Final peclion Inspection By Date, Inspection By to Fee Is Due: ❑ ANNUALLY ❑ PER UNIT a PER SITE ❑ EACH,- ❑ January l S Received By January 31 ❑ July 1 8 Received By July Jt REMIT 61LLttJG REMITTANCE L BASE E%PLANATION,; AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE ss � S LESS PRORATION ' PLUS PENALTY OTHER OTHER 16S°I , -1 - Recerved by Date Receipt No. Permit No, sauancq Dat Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SEIIVICES 16ol E.HAZELTON AVE.,P.O.Soo Me➢ STOCKTON,CA 95M1