Laserfiche WebLink
f -Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> rFOH-GFFICE USE:,,, _ APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> k-: (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> k <br /> I made in compliance with San Joaquin Co my Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address f City/Town <br /> Owner's Name Phone <br /> Address -- e City <br /> Contractor's Namer License#MEjrr671 Business Phone <br /> Contractor's Address 0< Emergency Phone <br /> is Certificate of Workman'sCompensation Insurance on File With SJLHD? Yes No <br /> r TYPE OF WORK (CHECK): '- NEW WELL❑ DEEPEN RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR L7 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy C <br /> I Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> II ❑ INDUSTRIAL4 11 CABLE TOOL Dia. of Well Excavation <br /> F S <br /> DOMESTIC/PRIVATE -' ❑ DRILLED Dia. of Well Casing <br /> ❑ D ESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ GRAVEL PACK Depth of Grout Seal s <br /> IRRIGATION, - -'•' } R j - <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> 1 <br /> ❑ DISP08AL r ❑ OTHERr Other Information _ <br /> ' ❑ GEOPHYSICAL ,! c Surface Seal installed By: <br /> PUMP INSTALLATION:` Contractor—_2 _ - <br /> a .a I. <br /> t Type of Pump H.P1 <br /> PUMP REPLACEMENT: ❑ State Work Done { <br /> PUMP REPAIR: 7 ❑ State Work Done 4•e.� <br /> I DESTRUCTION OF WELL: Well Diameter' = i Approximate Depth y <br /> Describe Material and Procedure ! <br /> f <br /> t I herekiy certify that I have prepared this application and that the work will be done in accordanc1 with San Joaquin County <br /> 4 ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. t <br /> Home owner,or licensed agent's signature certifies the following:"I certify that in the performance of thb 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 /> P <br /> Contractors hiring or sub-contracting signature certifies the fallowing:"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 w I call` a Grout 1 e ion prior to grouting and a final inspection. <br /> I Sig d X r - _ Title: Date: _ 7`—60 <br /> / <br /> I (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 <br /> � Q I <br /> Application Accepted By Date <br /> r <br /> Additional Comments: ) <br /> Phase II Grout Inspection Ph a 11 Fina inspection <br /> i Inspection By Date Inspecti y ti Date <br /> Fee Is Due: ElANNUALLY - ❑ PER UNIT ElPER SITE 11EACH ElJanuar 1 8,Received By January 31 ❑ Juiy 1 &Received By July 31 <br /> $ tt REMIT <br /> BILLING REMITTANCE <br /> I - BASE EXPLANATION 1 AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER r <br /> , "'Receivetl by Date Receipt No. Permit No. Issuance Hate -. Mailed Delivered ., <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES1601 E.HAZEL_TON AVE.,P.O.Box 2009 STOCKTON,CA 9520 <br />