Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL !/ <br /> ENVIRONMENTAL HEALTH PERMIT <br /> ' (COMPLETE IN TRIPLICATE) WATER QUALITY.;, <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joa uin Co my Or finance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address - City/TownG `�"� <br /> Owner's Name '- '' Phone <br /> Address City OEM% Abe- q7c &A"1107 <br /> Contractor's Name License Business Ph ne <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 ❑ WELL ABANDONMENT ❑ OTHER 0 PUMP INSTALLATION © PUMP REPAIR❑ <br /> REPLACEMENT A== <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other_ <br /> Property Line . Private Domestic Well . Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑, INSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> B DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION -❑ GRAVEL PACK Depth of Grout Seal <br /> I. ❑ CATHODIC PROTECTION' ❑ ROTARYTy e of Grout <br /> ❑ DISPOSAL ❑ OTHER ' ther Information <br /> ❑ GEOPHYSICAL' Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done _ _ <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter t l — Approximate Depth R} <br /> Describe Material and Procedure C <br /> O <br /> hereby certify that-I have prepared this application and that,the work will be done in accordance with San Joaquin County CN <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 /> ca!W a Gro t Inspection prior o gr offing and a f I inspection.- <br /> Signed isle: t:..eS� Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEP=SE USE ONLY rt ?} <br /> PHASE 1 <br /> Application Accepted By Date CCC777 <br /> Additional Comments: <br /> Phase 11 Grout Inspection a 111 <br /> Inspection ByDate Znuary <br /> Gti <br /> Fee Is Due: El ANNUALLY ❑ PER UNIT 13 PER SITE El EACH 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 /> PRORATION <br /> PLUS , <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No - Permit No, Issuance ate - Mailed Detivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />