Laserfiche WebLink
R Applications Will Be Processed When Submitted Property Completed. Be SureToSignTneAppllaauvr1. <br /> FOROFFICEUSE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) )'UMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) and/or install the work herein described.This application is <br /> L <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> made in compliance with San Joaquin County Ordinance No. 1$62 and the rules and regulations of the San Joaquin gcal Health District.. <br /> City/Town <br /> Exact Site Address <br /> h a Phone <br /> Owner's Name _ City <br /> AddressV" <br /> Contractor's Name License#/43776 Business Phone <br /> Emergency Phone - <br /> Contractor's Address a No } <br /> is Certificate of Workman's Compensation Insurance on File With JLHD? Yes DESTRUCTION❑ <br /> TYPE OF WORK (CHECK): -NEW WELL❑ DEEPEN 13 ' 'RECONDI N. <br /> WELL CHLORINATION El WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION is PUMP REPAIR❑ y <br /> REPLACEMENT❑ Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines <br /> Sewage Disposal Field <br /> Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well z Public Domestic.Well <br /> INTENDED USE TYPE OF WELL <br /> El INDUSTRIAL CABLE TOO <br /> ❑ T pia. of Well Excavation <br /> ® DOMESTIC/PRIVATE ❑ DRILLED Dia. of Weil Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> I ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> 11 DISPOSAL <br /> 13 OTHER Other Information <br /> Surface Seal Installed By: <br /> 13 GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump ) " -�- <br /> PUMP REPLACEMENT: ❑ State Work Done / <br /> PUMP- : State Work Done <br /> r DESTRUCTION OF WELL: <br /> 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 r <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 forwhich this <br /> ' permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I 'll call for a Grout Inspectio p or gr utin nd I I inspe <br /> ll <br /> e: �• Date: <br /> Signed <br /> (Draw Plot PI on Reverse Slde) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Da— <br /> Application Accepted By <br /> Additional Comments: a NI IIInspection r1 <br /> Phase I Grout Inspection 7 rf <br /> /v Date Inspection By Date <br /> Inspection-By � F <br /> �> <br /> ❑ PER SITE EACH ❑ January 1 &Received By January 31 ❑ July T&Received 13y July 31 <br /> Fee Is Due: [3 ANNUALLY UNIT ANNUALLY ❑ REMIT <br /> EXPLANATION BILLING - REMITTANCE $r AMOUNT DUE CHECKED <br /> BASE° DATE g DATE WMITTED AMOUNT <br /> FEE � - <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY. <br /> OTHER <br /> OTHER •'�C?} - <br /> Delivered <br /> Permit No. Issuance Date - Mailed <br /> Received by Date Receipt No. - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br /> 1601 E.HAZELTON AVE.,P.O-Box 2009 STOCKSON,CA 95201 <br />