Laserfiche WebLink
04 plications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> r FOR O'F'F"rCE USE: APPLICATION t <br /> (For Non-Transferable, Revocable, Suspendable) { <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> x <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetotheSan Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is y <br /> made in compliance with San Joaquin County Ordin nce No. 186 and the rules and regulations of the San Joaquinocal Health District. <br /> Exact Site Address + City/Town5�. /Ln.�. <br /> Owner's Name Phone U` <br /> Address City <br /> Contractor's Name License Business Phone�l/� � ', <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes Ix No <br /> i, TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ q <br /> REPLACEMENT❑ a <br /> r 1.. <br /> DISTANCE TO NEAREST: Septic Tank �f� Sewer Lines_sG� Pit Privy <br /> Sewage Disposal Field ,�� Cesspool/ eepage Pit Other 1� <br />( Property LineZo f+ Private Domestic Well �Q :+ Public Domestic Well I <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL © CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ 4' <br /> DRILLED Dia. of Well Casing r <br /> © DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing � 13 <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout e,IrmiL1 <br /> ❑ DISPOSAL ❑ OTHER Other 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 Approximate Depth <br /> Describe Material and Procedure <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 /> I will call fora ut I specti for to grouting and a final inspection. i <br /> Signed X Title: <br /> Date: G <br /> (Draw Plot Plan on Reverse de) <br /> FOR DEPARTMENT USE ONLY ; <br /> PHASE <br /> Application Accepted By Date/ i <br /> Additional Comments: <br /> ase 11 rout nspection e-ll Final 1 spection <br /> Inspection B Date Inspection By Date I <br /> Feels Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH January 1 &Received By January 31 ❑duly 1 &Received By July 31 i <br /> BILLING REMITTANCE $ �£ REMIT j <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE pC I�jY1 C O d7 <br /> LESS <br /> PRORATION <br /> PLUS <br /> '�--.PENALTY <br /> OTHER <br /> OTHER <br /> -7 g -13S� <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />