Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE 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 Districtfora 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 Jo quin Local Health District. <br /> Exact Site Address f[ Qt3dL -P ( L�ity/Town F)A.4,aA.2lcLl. �CGLl� <br /> ' Owner's-Name Phone -69,,221 <br /> .Jr Address = E. City' <br /> Contra'tor's;Name . - License#_.W4813 Business Phone S - <br /> Contractors Address 6 7/0 Emergency Phone 51/5-0.2 ZJ } <br /> Is Ceitificate of Workman's Compensation insurance on File With SJLHD? Yes No ~ <br /> d . <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ '# <br /> WELL CHLORITIATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 1, <br /> REPLACEMENT❑ <br /> t <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy ` <br /> Sewage Disposal Field loo , Cesspool/Seepage Pit Other <br /> _ i <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation— <br /> ( <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing - <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing l <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information ,-Tl&b <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor .� <br /> Type of Pump H.P. j <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 /> Home owner 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Insp ction prior to grouting and a final inspection. (� p <br /> Signed X Title: ; VeL•Date: 42 <br /> i <br /> raw Plot Plan on Reverse Side} <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _ gti <br /> Application Accepted By Date — V <br /> Additional Comments: <br /> �Groction *�P a III Fin Inspection <br /> Inspection Bate Inspection By Date <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 /> BASE EXPLANATION BILLING REMfTTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS I <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> i <br /> OTHER <br /> OTHER <br /> 02 �-6 �� to <br /> Received by Oate Receipt No. Permit No, Issuance Date Mailed Delivered <br /> k APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />