Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTheApplication. <br /> F6R oFViCE USE: APPLICATION <br /> (For Non-Transferable, 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 District fora permit to construct and/or install the work herein 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 /> Exact Site Address�,7/9�lc City/Town <br /> V i <br /> Owner's Name r;1Nd ,yPhone <br /> Address Voy, City / <br /> Contractor's Name G4Lf�{ f�Pi!!C1YG CSL, License# �6 Business Phone 2` <br /> '1 <br /> Contractor's Address 10n tS. XiLJPIY�7 Emergency Phone # <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD2 Yes No <br /> TYPE OF WORK (CHECK): NEW WELL R DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ a I <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ '` <br /> I <br /> DISTANCE TO NEAREST: Septic Tank _/00 F-7-' Sewer Lines Pit Privy <br /> Sewage Disposal Field�16a 1777�. Cesspool/Seepage Pit Other Cl <br /> Property Lin 'e �"Private Domestic Well Public Domestic Well <br /> I <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 C 166 <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal - <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> 13 DISPOSAL `❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <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 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 /> r <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> Ir 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:"l 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 I will call 1hr a Grout Inspection prior to grouting and a final inspection. <br /> Signed XTitle: Date: <br /> 91417.9 <br /> lip <br /> (Draw Plot Plan on Reverse Side) <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection P ase III Final Inspection <br /> Inspection By Date Inspection By Date 0 �b <br /> W KTX c <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 3#- ❑ u 1 &Received By July 31 <br /> REMIT <br /> BASF EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> f PRORATION <br /> PLUS <br /> PENALTY <br /> I OTHER S' <br />' OTHER <br /> -Received by Date Receipt No. -Permit No. issuance Date 'Mailed Delivered r] ' <br /> 111 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON, A 9 2 <br /> i <br />