Laserfiche WebLink
A. <br /> I aApplications Will Be Processed When Submitted Properly Completed. Be Sure ToSignTheApplication. <br /> Fof3FFjcE USE APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> ' (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Appl ication is hereby madeto the San Joaquin Local Health Districtfor a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 <br /> A`62 and the rules and regulations of the San Joaquin Lo Health District. <br /> Exact Site Address �� F ch a,/�'e N City/Town C <br /> I Owner's Name Phone <br /> k Address City <br /> Contractor's Name !/ License#,A6��-�L Business Phone <br /> Contractor's Address/ _ Emergency Phone —�-6� <br /> Is Certificate of Workman's Compensation Insura eon File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> € WELL CHLORINATION Cl WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT i <br /> DISTANCE TO NEAREST: Septic Tank Sewer LinesPit Privy <br /> Sewage Disposal Field n.LL a- ai Cesspool/Seepage Pit _,p+wa>v� Other <br /> Property Lines Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ` ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑,�,.B�DDOMESTIC/PUBLIC 13DRIVEN Gauge of Casing <br /> iRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> 1 ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump— U SII t1r -�_ H.P. <br /> PUMP REPLACEMENT: State Work Done " - /�=-o�`� �!� �� — <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> U <br /> ' I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County C <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 /> i <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.for a Grout Inspection prior to grouting and a final inspect' n. <br /> f Signed � �- -_=� Title: Date: <br /> (praw Plot Plan on Reverse Side) <br /> i <br /> FOR DEPARTME14T USE ONLY <br /> PHASE I \�} - c>. —�—�� <br /> t Application Accepted 8y Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection �Illnspectiion <br /> Inspection By Date InspeiicttJo�n ByDate <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE El EACH ❑ JanucrS y l &Received By January 31 ❑ July 1 &Received By July 31 <br /> REM#T <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 /> 4 <br /> OTHER <br /> s <br /> kReceived by Date Receipt No. " Permit No. Issua ce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />