Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTheApplication k <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> " PUMP&WELL , <br /> ' ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) (`� <br /> WATER QUALITY /�j <fem �d CX_ <br /> V Application is hereby made totheSan Joaquin Local Health Districtforapermittoconstruc n / stalltheworkherein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> City/Town <br /> Exact Site Address i� <br /> Owner's Name � L � Phone <br /> 4Ct City <br /> Address <br /> Contractor's Name �` License# Business Phone <br /> Contractor's Address <br /> Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL'N DEEPEN ❑ RECONDITION© DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ 11 <br /> DISTANCE TO NEAREST: Septic Tank I Sewer Lines Pit Privy <br /> Sewage Disposal Fiel 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 /> 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 /> ( ❑ DISPOSAL ❑ OTHER Other information <br /> 1:1 GEOPHYSICAL Surface,Seal Instnlip By: <br /> PUMP INSTALLATION: Contractor �1'� <br /> Type of Pump NH.P. <br /> PUMP REPLACEMENT:,. ❑ State,.Work.Done <br /> t 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 /> ' Home owner 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 /> 1 permit is issued, I shad employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to routing and a fina.LiosSapction. <br /> Signed X ` Title: Date: r <br /> {Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 c`,~w 6?��6 <br /> Application Acceptad-By Date <br /> Additional Comments: <br /> Phase II Grout Inspection * Phos III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January i &Received By January 31 ./6vQzwjys1v&Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> I FEE <br /> LESS <br /> PRORATION - <br /> I PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> YJ <br /> Received by Date Receipt No. Permit No - Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />