Laserfiche WebLink
Appllcations Will Be Processed When SubmittedProperly compietea. tiesure Ioa+gn I it:MPF-0—Fl. <br /> FOR OFFICE USE: _ APPLICATION <br /> _ (For Non-Transferable, Revocable,Suspendable) PUMP WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetotheSan Joaquin Local Health Districtfora permit to construct and/or install thew ork.hereindescribed.Thisapplicationis <br /> made in compliance with n Joa uin Coun y (rdinance No. 186OF 2 e rules and regulations of the San Jo u Local He D' <br /> made <br /> Exact Site Address <br /> City/Town <br /> Owner's Name <br /> If Phone <br /> e City -- <br /> Address <br /> ` Contractor's Name �` C lcense Business Phone <br /> Contractor's Address Emergency Phone U <br /> Is Certificate of Workman's Compensation WS <br /> s <br /> LL ranee on File With SJLHD? Yes No (� <br /> TYPE OF WORK (CHECK): NEW WEDEEPEN© RECONDITION❑ DESTRUCTION 13 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT .With <br /> 11PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank /00 Sewer Lines u Pit Privy ^ <br /> Sewage Disposal Field Cesspool/Seepage Pit �' Other <br /> Property LintPrivate Domestic Well r^ Public Domestic Well, - <br /> INTENDED USE TYPE OF WELL j,-j / <br /> [. ❑ IiyDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation !r <br /> I� ��,,�� I <br /> DOMESTIC/PRIVATE Z-15 BILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC 11 WIVEN Gauge of Casing <br /> Lel GRAVEL PACK Depth of Grout Seal <br /> 1:1 IRRIGATION . <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> j ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Sea In$talled By: Cyd <br /> PUMP INSTALLATION: Contractor <br /> { Type of Pump , _ H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> I DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> i Describe Material and Procedure <br /> r - <br /> i i hereby certify that 1 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 /> i 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." Q <br /> k � <br /> 1 II for a G out I ectiorli prior to grouting and a final inspection. <br /> S7 <br /> Signed Tllle: Date: <br /> (Draw Plot Plan on Revers Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> I <br /> Application Accepted By r Date 7 <br /> Additional Comments: <br /> Phase II Grout Inspection Kase NI Final In ection <br /> Inspection By - Date Inspection By Date /O <br /> -Fee IS Due: El ANNUALLY 71 PER UNIT ❑ PER 517E - ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> 1 i BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> 4. DATE DATE REMITTED .AMOUNT <br /> FEE <br /> LESS ' <br /> �-PRORATIONPLUS - <br /> k l <br /> 1, t PENALTYdo q <br /> OTHER <br /> I. OTHER - <br /> t <br /> Received by _ 'Date Receipt No,._ _ --.,Permit NoDelivered -• - <br /> { APPLICANT—RETURN`ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES -1601 E.HAZ£LTON AVE.;P.O.Box 2009 STOCKTON,CA 95201 <br />