Laserfiche WebLink
t Applications Will Be-PPOcessed Wher1-S i ted Properly Completed. BeSureToSign TheApplication. <br /> der APPLICATION <br /> FOR OFFICE USE: _ ; ` _ _ �(ForNo,--Transllerable, <br /> i - Revocable,Suspendable}} PUMP&WELL � I <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY- <br /> (COMPLETE IN-TRIPLICATE) i <br /> tom--Application-is-h reebymadetotheS'anJoaquinLocalHealthDistrictforapermittoconstructand/or install the work.hereindescribed.This application is <br /> � <br /> ".rr...�.ni�in compliance t n�Joaquin County Ordi ante N 1862 an he yes and regulations of the San Joaquin Loral Health District. _ <br /> Exact Site Address A � ' City/Town <br /> Phone 9 0 ZZ - <br /> Owner's Name <br /> Address <br /> F Z,LClty <br /> Contractor's Name IIS License# Business Phone S s - ; <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes _ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ W`ELL ABANDONMENT El OTHER ❑ PUMP INSTALLATION ElPUMP REPAIPM <br /> REPLACEMENT❑ -I. <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> ¢, <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL i ❑ CABLE TOOL Dia. of Well Excavation <br /> � i <br /> r .DOMESTIC/PRIVATE I ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION i ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION i ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL I Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H,P, <br /> PUMP REPLACEMENT: III ❑ State Work Done <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION OF.WELL: Well Diameter ! Approximate Depth <br /> Describe Material and Procedure <br /> II <br /> t I hereby certify that II 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 /> Home owner 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." V <br /> Contractor's hiring orisub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I w9l call for a Groutdl ,speclion prior to grouting and a final ins <br /> or <br /> Signed X <br /> Title: Date: f <br /> f f I�; (Draw Plot Plan onr Side) <br /> ' FOR DEPARTMENT USE ONLY <br /> PHASE I iate <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout Inspection / �sr Pfi ell nal Ins ec Ione <br /> Inspection By Date Inspection By <br /> ! Fee IS Due: ❑ ANNUALLY' ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Jul 1 &Received By July 31 <br /> REMIT <br /> BAS! EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE der ITTED AMOUNT <br /> FEE 'Y�JI� I 'Y�J <br /> t LESS <br /> PRORATION <br /> PLUS N <br /> PENALTY II. <br /> OTHER <br /> I� <br /> OTHER jl�l <br /> l� Received by Dste Receipt No - Permit No. lssua=6 Date Mailed Delivered <br /> ` STOCiCTON,CA 95201 <br /> APPLICANT—RETURNZELTON AVEP.O.ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA ., Box 2009 <br />