Laserfiche WebLink
Applications Will Be Processed When Submitted Properly omp e e . <br /> FOR OFFICE USE f APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) puMp&WELL .rlie <br /> 11 ENVIRONMENTAL HEALTH PERMIT <br /> l A UALITY <br /> (COMPLETE IN TRIPLICATE) �� <br /> Application is herebymadetothe anJoaquin�ocalHealthDistrictforapermittoconstructand/or install the work herein described.Thisappiicatianis <br /> made in compliant it$$h,,//San Joaquin Count rdinance No. 18 and tJa�r�le�Qnd�ulations of the San Joaquin Local District. <br /> Exact Site Addres I°t��* ° Axa - ��City/Town <br /> Phone �a <br /> E I <br /> Owner's Name p e <br /> 1=F t /V , City t <br /> Address � , ,,,, QS Business Phone gcl�" ' <br /> C <br /> Contractor's Name a d- /�f <br /> Od Li e se`# <br /> Contractor's Address <br /> --------"Emergency Phonel7�� � C�` yF <br /> iI <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No �N <br /> TYPE OF WORK (CHECK): NEW WELL A' DEEPEN C3RECONDITION❑ DESTRUCTION❑ Q . <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER PUMP INSTALLATION ( PUMP REPAIR© <br /> REPLACEMENT❑ 1�II <br /> I DISTANCE TO NEAREST: Septic Tank "'6— Sewer Lines Pit Privy Yfi i <br /> a " Sewage Disposal Fi?ld Z't�� Cesspool/Seepage Pit Other �y <br /> i_ <br /> Property Line Z_I�`Private Domestic Well/IPubiic Domestic Well <br /> INTENDED USE TYPE OF WELL l �r <br /> ❑ IN TRIAL ElCABLE TOOL Dia. of Well Excavation 6 S' <br /> IDOMESTIC/PRIVATE 11DRILLED Dia. of Well Casing <br /> I 11DOMESTIC/PUBLIC 13DRIVEN Gauge of Casing - d <br /> 13 IRRIGATION ❑ GRAVEL PACK Depth of Grout S al <br /> 1 ElCATHODIC PROTECTION 0-ROT4RY Type of Grout, G� <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> El GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor - ° <br /> Type of Pup <br /> mp H.P. <br /> PUMP REPLACEMENT: <br /> 11 State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> 1 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:"l certify that in the performance of the work forwhich this <br /> { permit is issued, I shall persons subject to workman's compensation laws of California." <br /> f7 will call for a r I e ion ri to grouting and a final inspection. <br /> Titiern n w - Date: r <br /> Si <br /> (Draw Plot Plan on Reverse Side) <br /> f FOR DEP RTMENT USE ONLY <br /> PH 1 Date �S <br /> Application Accepted By <br /> Additional Comments: <br /> Ph a Grout�I 'spection Ph a II Final Jnspection <br /> sn ;-4-tl1,Date Inspection By " L Date <br /> l Inspection By ! / <br /> tBy <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ElJanuary 1 &Received By January 31 J El July 1 &Receiv REMITUIy 31 <br /> I BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> i <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> C <br /> OTHER <br /> Date Receipt No. Permit No. Issuance Date Mailed �Delivered <br /> Received by <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL H ERYICES 1601 E.HAZELTON AVE.,YEP.O.Box 2009 $TOCKTON,CA 9520iC }-- <br />