Laserfiche WebLink
f' Applications ill Be Processed When Submitted Properly Completed.IB uW7tD,SiotYTtMApplt�tigr� I I <br /> FOR OFFICE USE: i APPLICATION r <br /> (For Non-Transferable, Revocable,Suspendable) MAY 26 1981 <br /> PUMP&WELL ' <br /> ENVIRONMENTAL HEALTH PERMIT <br /> _V,`JfN LOCAL <br /> (COMPLETE IN TRIPLICATE) 4-&5 �, , - -- ..WATER QUALII �� 7I di§�- r T 9Z — <br /> Application is hereby madeto the5an Joaquin'Local Health DiC str c�o ar�p rrt tocol'tstruct and!or instattf� Jabfk Pi�I�efibed.This application is <br /> made in compliance wit San Joaquin County Ordinance No.-1862 and the rules and regulations of the San Joaquin Local H Ith District. <br /> Exact Site Address t���'� �' RA� � City/Town <br /> I' Owner's Name Phone q/a7 C.. 2- t <br /> Address c,w T�tis C a �" .� 1 -is( v rut�a( t � <br /> p Contractor's Na <br /> License i��- Business Phone <br /> '7` �� <br /> t Contractor's A �eCsS � c. /e.�. Emergency Phone <br /> t Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> I, TYPE OF WORK (CHECK): NEW WELL&-f DEEPEN ❑ RECONDITION❑ DESTRUCTION[:] <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION [!'' PUMP REPAIR <br />` REPLACEMENT❑ it n <br /> DISTANCE TO NEAREST: Septic Tank s=° Sewer Lines / �~' Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit _ Other ___ <br /> Property Line/b Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL I) ❑ CABLE TOOL Dia. of Well Excavation Z <br /> U}'GOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> D IRRIGATION 11 5-15RAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION II &IF OTARY _ Type of Grout �\- <br /> t 13 OTHER Otherinformation r <br /> ❑ DISPOSAL 4 <br /> 11 GEOPHYSICAL i Surface Seal Installed By: <br /> II <IrS <br /> PUMP? INSTALLATION: Contractor <br /> I� Type of Pump � '� H.P. ` <br /> a PUMP,REPLACEMENT: ❑ State Work Done <br /> } PUMP REPAIR: ¢` ❑ State Work Done `^ <br /> 4 Approximate 5 <br /> DESTRUCTION OF WELL: I Well Diameter A PP Depth <br /> C Describe Material and Procedure <br /> I hereby certify that I Ihave prepared this application and that the work will be done in accordance with San Joaquin County <br /> { ordinances, state laws,i and rules and regulations of the San Joaquin Local Health District. w ` <br /> 6 Home owner or licensed agent's signature certifies the following:1 certify that in the performance of the work for which this permit q 1 <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> } r <br /> f 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 inspection. <br /> .-Signed X i Title:�k 2 - Dat0n : 1 �1 r; <br /> I (Draw Plot Plan on Reverse Side) _ F" <br /> II <br /> S 7 FOR DEPARTMENT USE ONLY {- l <br /> PHASE I1�1 1` �vl, i ` q`;+�'J <br /> Application Accepted By Date <br /> Additional Comments:- 'I <br /> 5" as I Grout Inspection a III Final Inspection <br /> Inspection By Date Inspection By Date Y t <br /> F. Fee Is Due: 13 ANNUALLY ❑ PER UNIT ❑ PER SITE C3EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> Ih BILLING REMITTANCE AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED <br /> AMOUNT <br /> . FEE <br /> LESS <br /> PRORATION _ <br /> PLUS <br /> PENALTY I� <br /> OTHER � <br /> OTHER <br /> � l <br /> Received by bate k Receipt No, Permit No... - - Issuance Date Mailed Dehvered a <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 - <br />