79-1361 - Laserfiche WebLink

Home Browse Search

Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. r, FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable, Suspendable) �. "ENVIRONMENTAL HEALTH PERMIT PUMP&WELL rp l (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is- made in compliance with San Joaquin Count Ordin nc No. 1�6 nd rules regulations of the San Joaquin Local Health District. 1 Exact Site Address City/Town r Owner's Name Phone Address City Contractor's Name License Business Phone Contractor's Address IP-4 , Emergency PhoneJA s 7 Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ bESTRUCTI01 WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK ' Depth of Gout Seal " ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information " ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done p� PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximatepepth 00 Qj�scribe M erial and Procedure r 3" hillnye 11 a.,14 IF � 4f�{ At G.0 e" e i I hereby certify that I have prepared this application and hat the work wi be done in accordance with San Joaquin Cou ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the-work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." I will call for a Grout Inspection prior to outing and a final inspection. Signed X Title: Date: (Draw Plot Plan on Reverse Side) r FOR DEPARTMENT USE ONLY PHASE I J §�I Application Accepted B Date Additional Comments: Phase II Grout Inspection hese III Final Inspection _ Inspection By Date Inspection By Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 BILLING REMITTANCE $ REMIT ### BASE EXPLANATION AMOUNT DUECHECKED y DATE DATE REMITTED ) AMOUNT FEE / LESS 7 PRORATION .I PLUS PENALTY i! I 1 OTHER { i L OTHER CI I_s Received by Date = Receipt No. Permit No. Issuance Date Mailed Delivered a "APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL.HEALTH PERMITlSERVICES 1601 E.HAZELTON AVE.,Ill Box 2009 STOCKTON,CA 95201 I"