Laserfiche WebLink
: . .-_ <br /> Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication. <br /> FOR OFFICE USE: / APPLICATION <br /> i19/ag (For Non-Transferable, Revocable,Suspendable) PUMP&.WELL <br /> R ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetotheSan Joaquin Local Health Districtfora permit to construct and/orinstallthework.herein described.This application is <br /> made in compliance with San Joa uin County Ordinance o.1§662 and the r les and re ulati ns of the San Jo u 1 oval Health District. <br /> Exact Site Address 3 !✓ ® + � r �� ity/Town 4 <br /> Owner's Name ( '� CQ� tip Phone <br /> Address ka City <br /> F Contractor's Name _, License# - 7L Business Phone <br /> Contractor's Address 7 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File r th SJLHD? YesNo <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR 13 Q' <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy -� <br /> Sewage Disposal Field - Cesspool/Seepage Pit Other <br /> I` Property Line Private Domestic Well Public Domestic Well <br /> r INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> I ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Insta ed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump S 6 P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> k DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> t Describe Material and Procedure Cy <br /> t h <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. 19- <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." <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 /> 4 I w'I tali for a Grout Insp 'o r' routing and a iinal inspection. <br /> t Signed Title: ?,� Date: <br /> 7L d <br /> (Draw PI Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> t PHASE " <br /> Application Accepted By Date <br /> t Additional Comments: <br /> Phase II Grout Inspection Phase Ill Final inspection r o0 <br /> Inspection By Date Inspection By ate b <br /> t <br /> -Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By.January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> f. PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> a _91 <br /> Received by - Date Receipt No. - Permit No. Issu nce Dae Mailed Delivered <br /> a. <br /> APPLICANT;;:RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2,009 STOCKTON,CA 95201 <br />