Laserfiche WebLink
�...r <br /> A�ica�n'WjI '13e�x5o�Sled Submitted Properly Completed. Be Skire o <br /> FOR OFFICE USE: I � II 4l 1. 1APPLICATION <br /> (For on rad slerable, Revocable, Suspendable) PUMP&WELL <br /> - AUG 26 1981ENVIRONIMENTAL HEALTH PERMIT <br /> WATERQUALITY <br /> (COMPLETE IN TRIPLICA W [,�/ j l s j r �i �t <br /> °, vet.. .. <br /> Application is herebymade�ot'hE o q}�in�ocal�fiealt#�Districtforapermittoconstructand/orinstallthework.hereindescribed.Thisapplicationls <br /> made in compliance with San b2(10 Cou`nty'O " like No. 1862 an the rules and regulat'on of the San aquinrLocal Health District. <br /> hit �y on <br /> Exact Site Address I 0 C) I <br /> Phone F <br /> Owner's Name <I d City p� f <br /> Address I " License#/ 1? Business Phone .� #' ; <br /> tr <br /> Contractor's Name r 'L <br /> ° P -Emergency Phone �., (C— <br /> Contractor's Address ,���� ' � -` �` ;, � No <br /> Is Certificate of Workman's Compensation Insurance on File With SIYes <br /> TYPE OF WORK (CHECK): NEW WELL❑pONDENTE❑❑' OTHEERO❑ ITI PUI. P INSTALLATION❑❑ PUMP REPAIR <br /> WELL CHLORINATION 11 WELL RBA � I <br /> REPLACEMENT 3 » ! <br /> Sewer Liries Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Cesspool Pit Other--------- <br /> Sewage <br /> Sewage'Disposal Field p <br /> Property Line Private DomesticiWell Public Domestic Well <br /> s r <br /> TYPE OF WELL <br /> INTENDED USE ,•. - "- <br /> ❑ INDUSTRIAL 11 CABLE TOOL -4 Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED ii Dia. of Well Casing , <br /> ❑ DOMESTIC/PUBLIC 11 DRIVEN �! Gauge of Casing <br /> .11 GRAVEL PACK!! tt Depth of Grout Seal <br />? ❑ IRRIGATION <br /> ❑ CATHODIC PROTECTION ❑ ROTARY ! � Type of Grout <br /> © DISPOSAL 13OTHER Other Information <br /> � Surface Seal.Lnstalled_By.: . <br /> k..��—❑,.GEOPHYSICL-A � <br /> PUMP INSTALLATION: y Contractor <br /> H.P. <br /> �TTyp�ee of Pump . J <br /> �i State Work Done r <br /> PUMP REPLACEMENT: l <br /> PUMP REPAIR: <br /> 11 State Work Done <br /> Well Diameter `! Approximate Depth _ <br /> DESTRUCTION OF WELL: �. �} <br /> Describe Material.,and Procedure <br /> I hereby certify that I have pre <br /> done inyaccordance with San Joaquin County <br /> pared this application and that the work will <br /> ordinances, state laws, and rules and regulationsII`of the San Joaquin Local Health District. <br /> I the work for which this Home owner or licensed agent's signature <br /> nen s certifies <br /> inannerlowing:"I as to becomelfy that in the subject to nce o <br /> or km nos compensation flaws of California." <br /> is issued, I shall not employ any p o <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify khat in the performance of the work for which this <br /> to workman's compensation-laws of California." <br /> permit is issued, I shall employ persons subject <br /> I will c or Grout Ins ciion prior is grouting and a lino/ inspG n• ('r <br /> t tate: 1Jj <br /> e: <br /> Signed X (prow Plot Plan an_Revers Side);`' <br /> ~ <br /> AENT_.USE"ONLYFOR DEPART <br /> PHASE) Date <br /> Application Accepted By I <br /> Additional Comments: 3 " <br /> n as it Final Inspection <br /> Phase II Grout Inspection ate. <br /> :I Inspection B " <br /> inspection lay � Date rI <br /> I[ 1 <br /> ❑ Januar 1 &Received. y January 3j ❑ July 1 &Received By July 31 <br /> Fee is Due: ❑ ANNUALLY <br /> PER UNIT PER SITE EACH Y REMIT <br /> _ a —CHECKED--'-- <br /> BILLING REMITTANCE .,_,_—�-:_----�------..—••'�AMOtJNi-1]t7E <br /> BASE XP-LQTiATION i! -DATE -- DATE 'REMITTED AMOUNT <br /> FEE• <br /> a LESS I� <br /> PRORATION <br /> 'PLUS <br /> PENALTY <br /> OTHER . <br /> OTHER <br /> _ .Permit No. lss once Dal Mailed_�., Delivered <br /> ' Received by Date Receipt No.slF -� �" - <br /> APPLICANT—RETURN ALL COPIES To: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HA2ELTON AYE.,P.O.Box 2009 STOCKTON,CA 95201 <br />