Laserfiche WebLink
i Applications Will Be Proc4`sed When Submitted Properly Completed.-Be Sure To Sign The Application. f , <br /> FOR OFFICE USE: APPLICATION �I <br /> (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) ADu �2�?� WATER QUALITY + <br /> lro�o 1 <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the wo2, 43-- <br /> rk herein describe This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joa Lin L al Health District. <br /> Exact Site Address 1601 l�/Z 02 _r-�p 1t. ity/Town Ca <br /> Owner's Name Phones <br /> Address 0 p n City G✓ <br /> Contractors Name P!L License# 7� Business Phone <br /> Contractor's Address mergency Phone <br /> Is Certificate of Workman's Compensation Insuranc on File With SJLHD? Yes L No <br /> TYPE OF WORK (CHECK); NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR L�-- <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank /L`Af As { ._ Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line/A T Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 9'IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL � ' <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: - Contractor V", u rd tj <br /> Type of Pump `tr<C ,b e H.P. �S <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: E State Work Done iL4_> <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 /> 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 /> permit is issued, I Shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout I p coon prior to routing and a final inspectio <br /> Signed X Title: Date: 70 <br /> (Draw Plot Plan on Reverse Side) t <br /> FOR EPARTME T USE ONLY <br /> PHASE I <br /> Application Accepted By 411-1 Date <br /> Additional Comments: <br /> Phase II Grout Inspection hase III Final Inspection _ <br /> Inspection By Date Inspection B Date <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BG REMITTANCE $ REMIT <br /> BILLING BASE EXPLANATION AMOUNT DUE CHECKED i <br /> DATE DATE REMITTED AMOUNT ' <br /> FEE <br /> LESS <br /> PRORATION 1r <br /> PLUS <br /> PENALTY <br /> 1 <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No, Permit No� Issuance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />