Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Complete`�16 S"%Wn'thevApWca it?Ad.i <br /> FOR OFFICE USE: APPLICATION J i Ir �,I I' <br /> w (For Non-Transferable, Revocable,l Susperidable) FEB 26 90,U&WELL <br /> ENVIRONMENTAL-HEALTH PERMIT <br /> WATERQUALITY .. . . SAN !� ^,t�ti;?'wl LOCAL <br /> (COMPLETE IN TRIPLICATE) �, HEAI TW DISTRICT <br /> Application is hereby madeto theSan Joaquin Local Health District fora permitto construct and/or instal ework herein described.This application is <br /> made in compliance wl hjSan Joaquin County Ordinance No.1862 and the rules and regulations of the.Sarf`Joaquin Local Health District. <br /> Exact Site Address /J r If, City/Towr ZSCA+Loito <br /> Owner's Name " Phone �Yr /.: c <br /> Address La # .., City �' t "e`. -��- <br /> 5a' + # _ Business Phone �W- 026 <br /> Contractor's Name + u h/^ License <br /> Contractor's Address 2 3w- F. Emergency Phh�oone/1yi S <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): - NEW . <br /> WELL❑ - DEEPEN"[] RECONDITION❑ DESTRUCTION❑ - <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT 9 <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit" Other <br /> - — _ <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL , ❑ CABLE TOOL Dia. of Well Excavation <br /> 0 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of'Casing <br /> ❑ IRRIGATION - -'❑ GRAVEL PACK F Depth of Grout Seal 1 <br /> ❑ CATHODIC PROTECTION -❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER r Other Information <br /> ❑ GEOPHYSICAL ` Surface Seal Installed By: w <br /> PUMP INSTALLATION: Contractor I <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done c <br /> PUMP REPAIR: ❑ State Work Done i <br /> DESTRUCTION OF WELL: WedDiarneter ' 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 forwhich 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 /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call f r.a Gro nsp tion prior to grouting and a final lnspectwm - _ - <br /> Signed X _ Title: ' Date: <br /> r 1 (Draw Plot Plan on Reverse•Side)'- x n <br /> FOR DEPARTMENT.USE ONLY + �, <br /> PHASE I <br /> Application Accepted By v - Date <br /> Additional Comments: Al <br /> Phase II Grout InspectionP a ell Final Inspectio <br /> Inspection By M fir+ Date Inspection B Date �� <br /> Fee Is Due: ❑ ANNUALLY ❑ PER'UNIT' ❑ PER SITE 't EACH• ❑ 'January 1 &Rece+ved By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE 'EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> 0Z) Oa <br /> FEE 0 { S <br /> LESS v . <br /> PRORATIONPLUS I <br /> w *f <br /> Y <br /> PENALT - <br /> " OTHER <br /> OTHER - - <br /> ' o` o� o�lo / S t7 . U <br /> Received by Date - -1, .Receipt No.' — -Permit No. > r-w v .Issuance Date . Mailed.. . - Delivered <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />