Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the`work herein described.This application is <br /> made in compliance with SanJoaquin County Ordinance N0. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address yL�j9-7e L -f 0". 1i- City/Town c- <br /> Owner's Name �Q�G/��S k 'a -vPhone <br /> AddressJ�?F��PJ�j�•J� � _ City <br /> Contractor's Name �.t a ?f C eLidense#3j01JtZ Business Phone- s% r 2 E 7 <br /> ' Contractor's Address Emergency Phone 6 !!W'' <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No LJ" <br /> TYPE OF WORK CHECK): NEW WE1 ' DEEPEN El `RECONDITI N❑ DESTRUCTION❑ <br /> WELL CHLORINATION 13 WELL ABANDONMENT ❑ OTHER ❑ PUMP. INSTALLATION. PUMP REPAIR <br /> REPLACEMENT❑ <br /> oil- <br /> DISTANCE TO NEAREST: Septic Tank,�;�j Sewer Lines Pit Privy <br /> - Sewage Disposal Fip{d1 f Cesspool/ epage Pit Other <br /> Property Line- .& Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL �y <br /> ❑ INDUSTRIAL I ❑ CABLE TOOL Dia. of Well Excavation <br /> & DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well'Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> � t <br /> 11IRRIGATION {f ,.,.,/ RAVEL PACK Depth of Grout Seal. <br /> 11 CATHODIC PROTECTION 1� ROTARY Type of Grout �T ['c1" ? <br /> ❑ <br /> DISPOSAL 13OTHER Other Information <br /> ❑ GEOPHYSICAL! AlSurface Seal installed By: <br /> PUMP INSTALLATION:. Contractor A er N <br /> Type of Pump, H.P.1 <br /> PUMP REPLACEMENT: ❑ State Work Done -- <br /> PUMP REPAIR: ❑ State Work Done f <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i ) <br /> I hereby certify that I have prepared this application 4nd that the work will be done in accordance with San Joaquin County t <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. . j f <br /> Home owner or licensed agent's signature certifies the'tollowing:"I certify that in the performance of tJ vork forwhich 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 Califorriia." ; <br /> I will c 11 for a Gr ut inspection prior, o grouting and a final inspection. 1 <br /> k 4 <br /> Signed X { Title: ' Dale, < _�` <br /> j (Draw Plot Plan on Reverse Side) <br /> 1: 1 � <br /> f FORC DEPAfR`i4ENT USE ONLY <br /> PHASE I k - m•'�'�.-�' <br /> Application Accepted By ` I wte <br /> ry <br /> Additional Comments: <br /> Pha so II Gr t Inspection -'P e' i"rial,inspection / <br /> Inspectn B Date. ���� Inspection By Date �l°-.;2 <br /> t _ _ , <br /> fee 1S Due:=❑ ANNUALLY ❑ PER UN1T ❑ PER SITE ❑ EACH © January 1 S Received By January 31 `❑'July 1'&`Received By'lu 3P'31— <br /> Fee <br /> BASE, EXPLANATION BILLING REMITTANCE $ '6 AMOUNT DUE CHECKED <br /> DATE h -DATE_ REMITTED j. AMOUNT <br /> FEE <br /> UU O <br /> LESS <br /> PRORATION <br /> PLUS :. .,,,,.�„-.`.,,. �•.-"."-"--==— ._. ......�. .yam may. .� - - - -^...PENALTY—-?--— <br /> OTHER "'r-•'..."�......y-« _ <br /> OTHER <br /> F <br /> OTHER - Y <br /> Received by Dater Receipt No, Permit No. I suance ,ate Mailed Delivered <br /> >~ ' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 96201 <br />