Laserfiche WebLink
Applications Will Be Processed When Submitted Properlyr..Complele .-� a" Iii vo Siglh�The App, <br /> FOR OFFICE USE: APPLICA`TIQN " <br /> (For Non-Transferable, Revocable,Susp rfdi &WELL <br /> ENVIRONMENTAL HEALTH PERMIT Locnt <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY. . [� 1 �• '' <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/oriri taHbjherein described.This application is <br /> made in compliance with San u <br /> JoaqA Coun .Ofdinance N . 1862-and the rules and regulations of the San J qui cal Health District. <br /> Exact Site Address a b d� ` City/Town <br /> Owner's Name�/!.� � V �' � Phone - �3 1 '- l .3 <br /> Address 6 City r <br /> Contractor's Name `Q License# �213 73 Business Phone 1 <br /> Contractor's Address 'Emergency Phone, �Cs + <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ '"DESTRUCTION[] <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR UK/ Cl�� <br /> REPLACEMENT❑ (- <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal-Field 4 Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> B INDUSTRIAL ❑ CABLE TOOL DiA. of Well.Excavation ~� <br /> ❑I DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> til DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing r <br /> ©. IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑'CATHODIC PROTECTION ❑ ROTARY. Type of Grout - 1 <br /> ❑ DISPOSAL ❑ OTHER Other Information t- <br /> ❑ GEOPHYSICAL - z - � Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 0.42_99-& �.L�-�' <br /> Type of Pump H.P._ Z O O 4 <br /> PUMP REPT=ACEMENT:=. �❑-State•Work Done-�-` - _ _ 0PUMP REPAIR: State Work Done r <br /> DESTRUCTION OF.WELL: Well Diameter 'Approximate Depth <br /> Describe Material and Procedure. <br /> s" <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 licensedagent'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 forlrohich this #! 1 <br /> 4 permit is issued, I shall employ persons subject to workman's compensation laws Of California." <br /> 9 rP <br /> r I will¢_ for Grout Insp 4 ton prior tgrouting and final inspection. .3 f J <br /> Signed X }' Date: <br /> , <br /> i (Draw Plot Plan on Reverse ode) <br /> J I <br /> i 3 FOR DEPARTMENT USE ONLY ' <br /> PHASE I l ` <br /> Application Accepted By ' Date , <br /> Additional Comments: t <br /> _ Phase II Grout Inspection base Final Inspection <br /> Inspection By Date Inspection By r to <br /> Fee Is Due. ❑ ANNUALLY ❑APER UNIT ❑ PER SITE ❑ EACH. ❑ January 1 &Received By January 31 ❑ July 1 &Redeived By July 31 <br /> REMIT <br /> BILLING REMITTANCE, $ <br /> ' BASE EXPLANATION - AMOUNT DUE CHECKED <br /> a DATE DATE REMITTED, AMOUNT <br /> FEE, <br /> r <br /> LESS w <br /> PRORATION <br /> PLUS <br /> PENALTY_ <br /> OTHER <br /> OTHER <br /> Received by _Y -Date- _ Receipt No, Permit No, Is uance D to Mailed - Delivered - .j.. <br /> j APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 <br />