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) <br /> ~~ ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> I (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 compliancelith,fin Joaquin Pounty inance No. 1862 and the rules and regulations of the San Joa uip Local Health District. <br /> is <br /> Exact Site Address_ � City/Town L L ^ � <br /> lp SCJ <br /> 41 Owner's Name Phone <br /> Address -1-%7'7 City <br /> Contractor's NameLicense# , Business Phone en2 71(In <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No / <br /> r �Q <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 IGO�.,._ Pit Privy <br /> j Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private t - Private Domestic Well Public Qomestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation J/ <br /> _ 4 <br /> DOMESTIC/PRIVATE DRILLED Dia. of Well Casingt I <br /> C1DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing _�� <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal t <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information N <br /> ❑ GEOPHYSICAL Surface Seal Installed By: .r' <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 /> i Home owner or licensed agent's signature certifies the following:"I certify that in the performanceof thework 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for <br /> /a`� Grout Inspection prior to grouting and a final inspection. L) /� <br /> r Signed X ,�„� p/U _ _ Title: Date: � -�gL� <br /> (Draw Plot Plan on Reverse Side) ` <br /> FOR DEPARTMENT USE ONLY <br /> PHASE..I <br /> F <br /> w App'j;ication Accepted By Date %\ <br /> Additional Comments: <br /> ' I ase 11 Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By ktA71 Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ElPER SITE ElEACH ElJanuary 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> i' BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE q3 �J,X1S <br /> } <br /> i LESS <br /> PROBATION <br /> PLUS <br /> PENALTY <br /> t <br /> OTHER <br /> OTHER <br /> o <br /> 5 <br /> Received by Date - Receipt No Permit No. Assuande Date Mailed Delivered <br /> 4 APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 20119 STOCKTON,CA J. <br />