Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be sure Iosign 1ne,rappncanvn <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin Count�r Ordinance No. 1862 and the rules and regulations of the San J aquin Local Health District. <br /> Exact Site Address 1 [ �I City/Town <br /> Owner's Name Phone <br /> Address �c. r7lCity <br /> Contractor's NameWc29-Py _ License# at',y��-Business Phone <br /> Contractor's Addresses—� Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? YesNo <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN IDRECONDITION DESTRUCTION© p� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ f { <br /> DISTANCE TO NEAREST: Septic Tank _ S�wer Lines_ '5�121 Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL f a <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> '90OMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 11, <br /> DOMESTIC/PUBLIC ❑-DRIVEN Gauge of Casing <br /> ❑ IRRIGATIONGRAVEL PACK Depth of Grout Seal <br /> El CATHODIC PROTECTION 1; OTARY Type of Grout Y <br /> 1) DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: _ 0 ,M <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P, <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR. ❑ State Work Done <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:1 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Ins ection prior to grouting and a final inspection. Q /, <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> �/ FOR DEPARTMENT USE ONLY / <br /> PHASE I DaE e_/74 <br /> Application Accepted By <br /> Additional Comments: <br /> 1 o spection / Q�G� Ph ell inal Inspection /may <br /> Inspection By � Date ! fly Inspection By Date ! <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 14 Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING HEMiTTANCE $ - AMOUNT DUE CHECKED <br /> DATE RATE REMITTED AMOUNT <br /> 6 <br /> :FFE____:�S <br /> PORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER / <br /> Received by ate Receipt No. Permit No. Issuanob Date Mailed Delivered <br /> APPLICA T—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />