Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR O_FFICE USE: APPLICATION �r <br /> (For Non-Transferable, Flevoca6ie, Suspendable) / PUMP&WELL - <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or i r stat I the work herein described,This application is <br /> made in compliance with San Joaquin Countysrdinan No. 1862 and the rules and regulations of the Sanoaquin Locaf Health District. <br /> Exact Site Address �SS City/Town <br /> Owner's Name Phone�6 <br /> Address City <br /> Contractor's Name License#S business Phone'— j <br /> Contractor's Address -"Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File Ah SJLHD? YesNo Q <br /> TYPE'OF WORK (CHECK): NEW WELL❑ -DEEPEN ❑._. o RECONDITION❑- DESTRUCTIO,_N,,❑w ='� " r�-- <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION > PUMP 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 OFWELL <br /> ❑�IN TRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED pia. of Weil Casing F <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 c. Surface S al Installed By: ,. <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump ! H.P. <br /> PUMP REPLACEMENT: ❑ State Work Don <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth _. J <br /> Describe Material and.Procedure J <br /> r/ e <br /> r I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County �/ l <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:^I certify that in the performance of the worktor 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 foilowing:"I certify that in the performance of the work for:which this <br /> permit is issued, I shall employ persons subject to workmari's compensation laws of California." <br /> II f r a Grout Insp ction prior to grouting and a final inspection. t <br /> Sig .Title: ` "L _ Date: ^� <br /> (Draw Plot Plan on Reverse Side) <br /> I FOR DEPARTMENT USE ONLY <br /> ' PRASE 1 _ <br /> Application Accepted By �2-GC r ,,�Q Date <br /> Additional Comments; <br /> R Phase li Grout InspectionP Ilf Final spection <br /> -Inspection By Date _.- Inspection By Date — �-,/—!E-z <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE _ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY .. <br /> a OTHER " <br /> OTHER <br /> 65 <br /> Received by Date Receipt No. .. .. _ Permit No. I suanc Dae Mailed Delivered + .,. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES r 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 85291 .4. <br />