Laserfiche WebLink
Applications Wi11 Be Processed WhenSubmitted Properlyt;ompletea. ne aure iaargn rFit!1ANr,1,�PLIVI1 <br /> FOR OFFICE USE: & <br /> II APPLICATION <br /> AIR <br /> (For Nan-Transferable, Revocable, Suspendable) PUMP&WELL ' <br /> II <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 nd the rules and regulations of the San Joaquin Local Health District, <br /> Exact Site Address 2qr52. I! 6_6 4, G u City/Town <br /> Owner's Name 4 QQ Phone <br /> Address - � City <br /> Contractor's Name S License# — L- usiness Phone S46 <br /> Contractor's Address 24 im Emergency Phone <br />` Is Certificate of Workman's Compensation Insurance on File ith SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION DESTRUCTION❑ iV1 ' <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 11 OTHER ❑ UMP INSTALLATION MP REPAIR❑ <br /> REPLACEMENT❑ �i e <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy •�..`l� <br /> Sewage Disposal Field --Cesspool/Seepage Pit Other , } <br /> Property Line Private Domestic Well Public Domestic Well ,I <br /> INTENDED USE �� TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> X DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing <br /> tJft-ZD4ttESTIC/PUBLIC 11 DRIVEN 4 Gauge of Casing T <br /> i ❑ IRRIGATION y ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION I ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL II ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL i� Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> II Type of Pump H.P, <br /> PUMP REPLACEMENT: II ❑ state Work Done <br /> z PUMP REPAIR:, -Ii ❑ State Work Done s' <br /> r <br /> DESTRUCTION OF WELL: !� Well Diameter Approximate Depth <br /> II Describe Material and Procedure 1 <br /> I hereby certify that 1 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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich this permit C\ <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 /> permit is issued, I shall employ persons subject to workman's compensationElaws of California." oqx <br /> L <br /> I ill call for a Grout Insp ion rior outing and a final inspection. S <br /> Signed - Title: t <br /> wl� Dae: <br /> li (Draw Plo tan on Reverse Side); s <br /> II i1 FOR EPARTMENT L' ONLY V <br /> PHASE 1 7,,k L <br /> Application Accepted By 'i Datr� <br /> Additional Comments: <br /> Phase 11 Grout Inspection i se final Inspection <br /> Inspection By Date Inspection B Date <br /> :II <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Januaryl &Received By January 31 ❑ duly 1 &Received By July.31 <br /> t REMIT <br /> BASE jXPLANA,110N BILLING REMITTANCE? $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> aG a <br /> p FEE <br /> LESS <br /> PRORATION - - <br /> PLUS <br /> I PENALTY I' <br /> OTHER <br /> JI <br /> OTHER I. <br /> tf is '--7 471 1T_-_ o�s3 � � <br /> r Received by Date dReceipt 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 />