Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Co d�ttre�o-3ign�oe�Ap�tlon. <br /> FOR OFFICE USE: APPLICATION OODU <br /> ;USE (For Non Transferable, Revocable, e 1 <br /> 5 UMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> t�' 2o 09 <br /> (COMPLETE IN TRIPLICATE)x ( ,.,fJO/l/oQ fEu d/JW <br /> WATER QUALITY s� <br /> Applicationishereby made totheSan Joaquin Local Health District fora permittoconstructand7o� sjtlJ.t�l�7nrorkhereindescribed.'Th+sapplicationis <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San oaquin Local Health District. <br /> Exact Site Address-A-3 ova 's � ?-^ (Zc4 City/Town �f <br /> j Ow.ner's Name �'-- Phone " eA <br /> _'Address ti City <br /> Contractor's Name License# JWIQ Business Phone_ 2-�'� 1 <br /> I: Contractor's Address U 4 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 1--� Na — <br /> TYPE OF WORK (CHECK): NEW WELL Kr DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ -4 <br /> WELL CHLORINATION E] WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> k 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 /> I INTENDED USE TYPE OF WELL <br /> BLE TOOL Dia. of Well Excavation <br /> ❑ INDUSTRIAL ❑ CA <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing .. <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION.: ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC P'iOTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL y' ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL'.. Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor e <br /> j" Type of Pump H.P. f <br /> i PUMP REPLACEMENT: State Work Done �` � .ee o�Q = <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Dept <br /> Describe Material and Procedure 0 lee <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 /> 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 forwhich this <br /> ject to workman's compensation laws of California." <br /> permit is issued, 1 shall employ persons sub <br /> Iwill c II fora G Inspection prior to grouting and a final inspection. <br /> Signed `Title: Date: <br /> E?A -C� <br /> (Draw Plot Plan on Rev se Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I --�a� <br /> Application Accepted By Date <br /> ! Additional Comments: . <br /> i Phase II Grout Inspection 7v.,[3y <br /> al InspectioInspection By Date Inspection Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Ruary 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $. AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> cm <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> '. APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES -. _ 1.601 E.HAZELTON AVE.,P.O.Box 2009 ,meSTOCKTON,CA 95201 <br />