Laserfiche WebLink
Applications Will Be Processed.When Submitted Properly Completed. Be Sure To SignTheAPPIlIcallion. <br /> IFORFFICEUSE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELLENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application <br /> made in compliance with an Jt aquin County Ordi ance No. B 2 and the rules and regulations of the Sa Joaqui oCal Health i�rict. <br /> _ City/Towne o U <br /> Exact Site Address <br /> Owner's Name (�1,�L�j Y^� Phone <br /> Address City C, <br /> Contractor's Name f �i Icense# Business Phone <br /> Contractor's Address blu Emergency Phone <br /> 4, Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No C3 <br /> TYPE OF WORK (CHECK): NEW WELL, DEEPEN ❑ RECONDITION DESTRUCTION❑ <br /> j WELL CHLORINATION 13 WELL ABANDONMENT © OTHER El PUMP INSTALLATION 13 PUMP REPAIR❑ <br /> r REPLACEMENT❑ I / . <br /> Pit Priv <br /> DISTANCE TO NEAREST: Septic Tank d Sed er Lines Y <br /> Sewage Disposal Field JD0 +, Cesspool/Seepage Pit Other <br /> Property Line Jo `f Private Domestic Well�� Public Domestic Well <br /> INTENDED USE TYPE OF WELL �r <br /> ❑ INDUSTRIAL ❑ GABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> 13DOMESTIC/PUBLIC 11DRIVEN Gauge of Casing f <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> Y ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL OTHER Other Information. <br /> ❑ GEOPHYSICAL Surface Seal Installed By: _0t-I&e_ 6 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> 4 PUMP REPAIR: ❑ State Work Done <br /> r DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> ti <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Courtty <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 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 /> I. permit is issued, I shall employ per ons subject to workman's compensation laws of California." <br /> t I wi II for a out pec <br /> n for to grouting and a final inspection. I <br /> Signed X <br /> Title: �``: Date: <br /> (Draw Plot Plan on Reverse Si <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I { Q� Date <br /> I Application Accepted By <br /> a Additional Comments: <br /> Phase It Grout Inspect'p nPhase Ili Final Inspection <br /> Inspection By r'v ftfi <' 5 4ft4p , inspection By Date <br /> ' Fee Is Due: ❑ ANNUALLY ❑ PER UNIT El PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMITu y 31 <br /> r, BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> { j D <br /> FEE <br /> k. LESS J <br /> I PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> C/-zy) <br /> r OTHER <br /> Received by t bate Receipt No. Per it. o. t I sua6/n Date Mailed Del'svered <br /> I. APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />