Laserfiche WebLink
u ; " Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sin plication. <br /> FOR,:oFFICE USE: <br /> APPLICATION Z ° <br /> (For Non-Transferable, Re vo ZRIMIT <br /> dJVe� <br /> J PUMP&WELL <br /> ENVIRONMENTA4 HE - �9g1 <br /> (COMPLETE IN TRIPLICATE) WATO QUAL! p?P, S O <br /> Application is hereby madeto the San Joaquin Local Health District for a permit to construct and/or install th.@w h jn described.This application is 1 <br /> made in compliance with San Joaquin oun Ordinance No. 1 22Qand the rules and r do pf lid E l[in Local Health District. <br /> Exact Site Address -� lei ' i� <br /> Owner's Name < Phone ( �"` �� <br /> Address Al 4, 344 City <br /> Contractor's Name 0 License#16 7-3 Business Phone <br /> Contractor's Address f 2)6 :22 , Emergency Phone F(. —1 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHO? Yes 1'--_ No V 4 <br /> TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION 13WELL ABANDONMENT 11OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENTS, <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ NDUSTRIAL 13CABLE 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 /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor AL <br /> Type of Pump H.P. <br /> PUMP REFfLACEMENT: U'State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Wel I Diameter Approximate Depth <br /> Describe Material and-Procedure <br /> i <br /> I hereby certify that I have prepared this application and that the work will be done-in accordance with San Joaquin County rn <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:�"l 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 ot_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 California." <br /> I will Ifo a Grout ns coon prior to gr ting and a final Insp tion. �! <br /> Signed X Title, 1 Date: lu <br /> (Draw tot Plan on Rever Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By aNLy, Date <br /> Additional Comments: <br /> Phase II Grout Inspection h e III Final Inspection, �� <br /> Inspection By Date inspection By Date <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31, ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION - AMOUNTDUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE � <br /> r _ <br /> LESS _ <br /> PRORATION <br /> PLUS <br /> PENALTY `-- <br /> OTHER <br /> I <br /> OTHER <br /> Received by Date Receipt No, Permit No. Issu nce Date Maileh Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1001 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />