Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. _ e <br /> F•OR OFFICE USE: APPLICATION . / <br /> - (For Non-Translerable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> 4 <br /> Application is hereby made to the San Joaquin Local Health District fo r a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin Coun y Or ante No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address^ G City/Town <br /> - <br /> Owner's Name 'f" r Phone <br /> Address Z <br /> City A912 �-� . <br /> Contractor's Namel? License#IYU Business Phone <br /> Contractor's Address V. 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 ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT© <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy 16- <br /> O <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL i <br /> ,❑ INDUSTRIAL C1 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 /> ❑ DISPOSAL ❑ OTHER Other Information 1. <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> i <br /> Type�f Pump H.P. l <br /> PUMP REPLACEMENT: 2 State Work one <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth � <br /> Describe Material and Procedure 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 /> 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 signZuting <br /> ertifies the following:"I certify that in the performance of the work for which this <br /> permi sued, I shall employ persons suo;ta <br /> man's compensation laws of California." <br /> I will call f r a Grout In ectio r to final inspection. <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspectionse II Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January t &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE REMIT <br /> AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT ` <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER i <br /> OTHER <br /> n <br /> Received byD•ate Receipt No. Permit No, Issuance Gate Mailed Delivered i <br /> APPLICANT—RETURN ALL COPIES TO;. ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 't4t <br />