Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Aplplicattion. - Y, <br /> F R OFFS USE: �,f ` APPLICATION' T � ,��� <br /> +. � : �• <br /> (For Non-Transferable, Revocable, Suspendable) , <br /> PUMP&�ftl.l: - <br /> _ ENVIRONMENTAL.HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY�- <br /> Application is hereby madeto the San Joaquin Local Health Districtfora permit to construct and/or install theworkherein described.Thisapplication is `' <br /> I made in compliance wi S h Joa uin County Ord' No. 1862 and the les and regulations of the San J aquin Local Health District- <br /> Exact Site Address 1. f City/Town <br /> Owner's Name Phone � � V <br /> i Address f City <br /> Contractor's Name License# Business Pine L 1 <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> i TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION DESTRUCTION❑ <br /> ` WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR 13 �1 <br /> t REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> t Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well_ <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> X 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 /> k ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Sur Se 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 1 will call for a Grout Ins ection prior to grouting and a final inspection. / <br /> I Signed X Title: Date.A4 <br /> r (Draw Plot Plan on everse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By, hf v ���`� Date <br /> Additional Comments: <br /> Phase II Grout Inspection !% Ph I Inal Inspection <br /> Jam` <br /> Inspection By Date Inspection By �� Date <br /> i Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31, ❑ July 1 &Received By July 31' <br /> BILLING REMITTANCE $ <br /> REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> $ AMOUNT <br /> FEE <br /> LESS <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> l <br /> OTHER <br /> - I V L C) '+� <br /> I U <br /> E Received by - Date Receipt No. Permit No. - Issuance D to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ..,1601 E.HAZELTON AVE.,P.O-Box 2009 STOCKTON,CA 95201 <br />