SU0014620 - Laserfiche WebLink

Home Browse Search

' Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. / t FOR OFFICE USE: ' APPLICATION n t •Non-Transferable, Revocable, Suspendable) •yi PUMP&WELL 1 ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or.install the work herein described.This application is W made in compliance with San Jo2aquin Coou,n�—ty Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address 3g t 0.�e.1 o/ 11- 71A� - Oity/Town ti Owner's Name Phone' Address City i S Contractor's Name License tL33B2t7 / Business Phone-�4 ,�, Contractor's Address Emergency Phone y Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes _ No ^e TYPE OF WORK (CHECK): NEW WELL DEEPEN Q RECONDITION 13 DESTRUCTIONO WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR 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 TYPE OF WELL. ❑ INDUSTRIAL ❑.CABLE TOOL- Dia. of Well Excavation DOMESTIC/PRIVATE ❑ DRILLED Dia.of Well Casing Q DOMESTIC/PUBLIC Q DRIVEN Gauge of Casing I� ❑ IRRIGATION ❑ GRAVEL PACK t Depth of Grout Seal - ❑ CATHODIC PROTECTION t7 ROTARY Type of Grout ❑ DISPOSAL / ❑ OTHER' Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTAkCATION: Contractor -a o �C'Q .� C Type of Pump H.P.JF PUMP REPLACEMENT: 0 Stale_Work Done PUMP REPAIR: State Work Done DESTRUCTION OF WELL; •Well Diameter' Approximate Depth tl Describe Material and Procedure I hereby certify that I have prepared this application and that the work will be done in'accordance with$an 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 m6ner as to become subject to workman's compensation laws of California." Contractors 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." 1 will c Grout Inspection prior to grouting and a final Inspection. _, I I Signed X Q4a_ ' Title: 0i a - I Date: /( —1 (Draw Plot Plan on Reverse Side) ) FOR DEPARTMENT USE ONLY PHASE'I Application Accepted By ` I Date Additional Comments: Phase II Grout Inspection.. Ph III Final Inspection Inspection By ^ Dale Inspection By Fee Is Due: C1 ANNUALLY '❑ PER UNIT 11 PER SITE ❑ EACH I—) January1 8 Received By January 31 .d Received By July 31 I BILLING REMITTANCE $ I REMIT BASE EXPLANATION DATE GATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE 1$ 00 LESS ' PRORATION j PLUS PENALTY ') OTHER OTHER Received by Dale ReceiptReceipl NO��Permlt No. Inuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES teat E.HAZELTON AVE.,P.O.Ba.2009 STOCKTON,CA 25201