SU0014620 - Laserfiche WebLink

Home Browse Search

Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. )) FOR OFFICE USE: - APPLICATION ( 'on-Transferable,Revocable,Suspendable) / PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to 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 Joaquin C unty Ordinance No. 1862 and the rules/a]nd regulations of the San Joaquin Local Health District. i Exact Site Address � � �J=t: Citylfown �t Owners Name ftz�yJ�� -� } � Phone Address2 T _ City I Contractor's Name1in< _-, .r`� License#,�-3FrBusiness Phone Contractor's Address Emergency Phone Is Certificate of Workman's Compensation Insurance on,File With SJLHO? Yes No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTIO,,N..,,❑91----16 WELL CHLORINATION 13 WELL ABANDONMENT 11 OTHER 13 PUMP INSTALLATION e+--'PUMP REPAIR 13 REPLACEMENT❑ 4. 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 11 INDUSTRIAL El CABLE TOOL Dia. of Well Excavation - { EaINDOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing { Q DOMESTIC/PUBLIC Ca DRIVEN Gauge of Casing ❑ IRRIGATION Q GRAVEDPACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OT,F�ER - Other Information 11 GEOPHYSICAL '�••.t Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump 1... H.P. 7 PUMP REPLACEMENT: ❑ State Work Done . PUMP REPAIR: ❑ State Sdork Done _ DESTRUCTION OF WELL: Wel) Diameter Approximate Depth Describe Material and Procedure (pW I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County d` ordinances,state laws,and rules and regulations of the San Joaquin Local Health District. Homeowner 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 subcontracting signature certifies the following:"1 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 call er-a Grout Inspecllo prior to grouting and a final Inspection. . Signed X -- Title: "P- /L . Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I Application Accepted By- Date Additional Comments: Phase 11 Grout Inspectionse F at Inspection Inspection By Date Inspection.By ,>�v; --= Date Fee Is Due: ❑ ANNUALLY ❑ PER LINIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July 1 d Received By July 31 REMIT BILLING REMITTANCE $ BASE EXPLANfION AMOUNT DUE CHECKED �. DATE DATE REMITTED AMOUNT FEE A 145 * 45 LESS PRORATION PLUS PENALTY OTHER OTHER Received by Dale Receipt No. Pe,.it No. IssuanC6 Dale Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE,P.O.Box 2009 STOCKTON,CA 95201