Laserfiche WebLink
Applications Will Be Processed When Submitted Properly CompleteddeTo Sign The ApplicatikW <br /> FOR OFFICE USE: APPLICATION L11C � p 1980 <br /> (For Non-Transferable, Revocable,Suspendable) U <br /> ,p� <br /> ENVIRONMENTAL HEALTH PERMIAN ��r•. ,, 1 <br /> IMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY HEALTH DISTRICT d, i <br /> Application is hereby made to theSan Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in cam lian }}�� ui ppr n No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> - Exact Site Address City/Town Mts• Ca= <br /> Roy St;romgren ,`� <br /> Owner's Name Phone <br /> Address 1209 W. Williamson „ an lecao . city M� <br /> Jq 0 � 54416 <br /> Contractor's Namell 5 Main t. License# Business Phone { <br /> Contractor's Address P. D� Emergency Phone <br /> l Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes % No ZA <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ l. <br /> j WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR El <br /> REPLACEMENT❑ <br /> (. DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy _ <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Li6e Private Domestic Well Public Domestic Well T <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing Q- \ <br /> ❑ <br /> IRRIGATION -�❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface,Seal Installed By: ZN <br /> f A.&. B. Electric <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> ~asPUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> } Describe Material and Procedure <br /> J <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 1 will.call f r a Gr ut Inspection prior to grouting and a final inspectio <br /> Signed X - - 9' 2-`-.'� Title: Dale:-- 2 <br /> 4 (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE [ ^_-. - � j <br /> Application Accepted By 6t � Date `0T <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> I Inspection By Date Inspection By \0�01 Date\. ] " <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 8 Received By July 31 <br /> I REMIT- <br /> BILLING REMITTANCE $ .K <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> �~ FEE <br /> -LESS <br /> PRORATION <br /> PLUS -� f <br /> PENALTY t <br /> F OTHER <br /> OTHER fi <br /> B 6C <br /> Received by Date Receipt No. 'Permit No.. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: . .ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009. STOCKTON,CA 9520 <br />