Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> _..FOR-OFFICE USE: APPLICATION <br /> (For Non-Transierable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install thework herein described.This application is 4 <br /> made in compliance with San Joaquin County9rdinance No. 1862 and the rules and re lations of the Sanoaquin Local Health District. t <br /> Exact Site Address P/ f� b Cr, P City/Town .� '� <br /> Owner's Name �•�• 4� Phone <br /> Address City /� <br /> Contractor's Name til'-1: r-4e,- cense# �F, *G 76usiness Phone �/6 --571 c9-2-39 <br /> Contractor's Address a[?-C.P-'a`wee• A2 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELLK DEEPEN ❑ RECONDITION❑ DESTRUCTION. co X <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 11OTHER ❑ PUMP INSTALLATION 13PUMP REPAIR❑ <br /> REPLACEMENT❑ <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 /> <r <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC X DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION A ROTARY Type of Grout � �`�{� <br /> ❑ DISPOSAL ❑ OTHER Other Information L <br /> .GEOPHYSICAL Surface Seal Installed By: afcwr Tom' <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 f- Approximate Deptho <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 I <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. i <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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> C,,I,lfgGrout fpecti prior to grouti�anda final inspection. <br /> Signed XTitle; ! �� F"' tate: <br /> (DraPlan on Reverse Side) t <br /> FOR DEPARTMENT USE ONLY a <br /> i <br /> PHASE 1 1 <br /> Application Accepted By Da e <br /> Additional Comments: <br /> Phase II Grout Inspection Ph,sf III Final Itispecti ri <br /> Inspection By Date Inspection By Date fa <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT r <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED ` <br /> DATE DATE REMITTED AMOUNT <br /> FEE A <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> r OTHER <br /> v <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> L' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />