Laserfiche WebLink
Applications Will-Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FDR-OF Mi E USE: APPLICATION 1 <br /> 1 <br /> (For Non-Tragoferable, Revocable, Suspendable) <br /> ENVIRONMENTAL. HEALTH PERMIT PUMP&WEA! <br /> !(COMPLETE IN TRIPLICATE) `190-03 S _6444,,,1 ,q,�EWATER QUALITY <br /> } Application is hereby made to the San Joaquin Local Health District fora permit to construct arid/or install-the work herein described.This application is J <br /> made in compliance,vgi S n Joaquin County rdinanco. 1862 and the rules andle ons of the San Joaquin LO al Health District. <br /> Exact Site Address W City/Town <br /> Owner's amJAZ <br /> AddressAddress City <br /> Contractor's Name <br /> Licenser �1 L Z' Business P one f <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes _ No <br /> TYPE OF WORT( (CHECK); NEW WELL Pa DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR D <br /> REPLACEMENT❑ 1 <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines f Pit Privy <br /> Sewage Disposal Field ��Z-� Cesspool/Seeopage Pit �� Other <br /> Property LinePrivate Private Domestic Well �p Public Domestic Well INTENDED USE USE TYPE OF WELL i <br /> 1+ <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation--J-2 <br /> I DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing �r _1Z <br /> 13DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing O <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal r l <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ 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 /> I <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, to <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 lk <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." D <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ ersons subject to workman's compensation laws of California." <br /> E, <br /> I w' all for a ro nsp i,ri prior to grouting and a final inspection. � F, <br /> Signed X Title: 1 Date: <br /> ! <br /> (Draw Plot Plan on Reverse ide) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE l <br /> Application Accepted By Date 79 <br /> Additional Comments: <br /> fyv,` <br /> Ph a a #'Grout I pectio <br /> / n hase.1 I Final Inspection_ _ <br /> Inspection By vv Date_ ��// �/� Inspection B Date <br /> ' Fee Is Due: ❑ ANNUALLY - ❑ PER UNIT ❑ PER SITE ❑ EACH -❑ January 1 & eceived By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEES �� • <br /> t LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER ` <br /> - <br /> Received by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> i;: APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601E.HAZELTON AVE.,P.O.Box 2009 STOCKTON, <br />