Laserfiche WebLink
, A Plications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application n � T' <br /> FOR G*FFICE USE:p' J� / � APPLICATIONAC <br /> ' a°(���Xi"r�_R (F+wN n-Tr sferable, Revocable, Suspendable) (; <br /> ENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin o"111thtrict fora permit to construct and/or install the work herein described.This application is <br /> I made in compliance th n Joaq in ou Ordi ante No. 1 62 and therule„g and regulations of the San oaquin Local Health District. <br /> J <br /> Exact Site Address City/Town 4 <br /> f �I � <br /> Owner's N Phone j <br /> Address47�_� _A <br /> City <br /> Contractor's Name License Business Phone(p _q ) <br /> Contractor's AddressC�YT� ' -4��� Emergency Phone r - 1 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> No <br /> TYPE OF WORK (CHECK): NEW WEL00-_ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑' WELL ABANDONMENT ❑ -OTHER ❑ PUMP INSTALLATIONV17% PUMP REPAIR❑ <br /> REPLACEMENT❑ -.•- <br /> DISTANCE TO NEAREST; Septic Tank01 <br /> Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line r <br /> � Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL 39-CABLE TOOL Dia. of Well Excavation <br /> IR-DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing � <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 1 <br /> 11 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> © CATHODIC PROTECTION ❑ ROTARY Type of Grouth <br /> ❑ DISPOSAL ❑ OTHER Other Information +y <br /> ❑ GEOPHYSICAL Sur ce Sial Installed By: # <br /> PUMP INSTALLATION: Contractor y <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth ) <br /> t,` 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 taws, 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 certities'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 compesation laws of California." <br /> 1II for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X will Title: <br /> no <br /> Oa#e: <br /> (Draw Plot Plan on Reverse Side) - JDate <br /> FOR DEPARTMENT USE ONLY . <br /> PHASEIApplication Accepted By OAdditional Comments' h II Grout Inspection h s III Final InspectioInspection By Date C Inspection By Date <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January— Received By Januar 31 <br /> - 1 &RY ❑ July 1-&Received By July 31 ) <br /> - BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE - AMOUNT DUE CHECKED <br /> FEE AMOUNT F <br /> LESS <br /> i <br /> PRORATION <br /> PLUS _ .. <br /> PENALTY <br /> OTHER - <br /> f <br /> OTHER�- - -- — - <br /> �G �- `�S� j a 5 <br /> Received by ate Receipt No, Permit No- { <br /> ce Date_ Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,:IssuanGA 95201 3 <br />