Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The pp cation. <br /> APPLICATION <br /> FOR'®FFIE USE: <br /> (For Non-Transferable,•Revocable,Suspendable) PUMP&WELL <br /> 1 ENVIRONMENTAL HEALTHPERMIT <br /> WATER QUALITY r , ti T4s <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby madetothe San Joaquin Local Health District fora permit taconstruct and/or Install the work here described.This.application is <br /> i made in compliance with an Joaquin Count Ordinance No. 1862.and the rules and regulations of the San Joa n Local Health District. <br /> Exact Site Address <br /> E, elm City/Town <br /> . , u Phone <br /> Owner's Name .0 <br /> Address I^ City: <br /> T ;,. '` License# f; Business Phone <br /> Contractor's Address No <br /> Contractor's Name y� <br /> c >t ,`' -r�,ti Emergency Phone . <br /> ,X _n <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECKJ: NEW WELL❑'. DEEPEN 11 _ 'RECONDITION 11 DESTRUCTION _ <br /> WELL-CHLORINATION 11 WELL ABANDONMENT <br /> OTHER E] PUMP INSTALLATION �� PUMP-REPAIR❑ } <br /> REPLACEMENT❑ T W <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines, A-10 Pit Privy <br /> Sewage Dispos,�aall F�iie�lld- Cesspool/See age Pit Other' <br /> Property Lined, Private Domestic Well S� 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 /> I ❑ DOMESTIC/PUBLIC ❑ DRIVEN s Gauge of Casing I ,` <br /> ❑ IRRIGATION € ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> 1. ❑ DISPOSAL ❑ OTHER Other Information , <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> ( <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: -y❑_State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> 1'0-6 7' Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Des ibe Material and Procedure -_ <br /> l I hereby certify that I have prepared this application and that the'work will be done in actor nce with San Joaquin_County <br /> ordinances,state laws, and rules and regulations of the San Joaquin Local Health District. Q) <br /> Home owner or licensed agent's signature certifies the following: work for which this permit <br /> "I certify that in the performance of the . C <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California.". <br /> I Contractor's hiring orsub-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 w' call for a Grout Inspec ion prior to grouting and a final inspe tion. <br /> Title: D7ale <br /> Signed X: t <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 <br /> Application Accepted By C/Additional Comments: <br /> Phase 11 Grout Inspection a III Fina specon <br /> Inspection By Date _ Inspection By date. - <br /> } Fee Is Dile: ❑ ANNUALLY "'� ❑ PER UNIT� ❑ PER SITE ❑ EACH•,' ❑ ary 1 &Received By January 31 ❑ July 1 &Received By July 31 - <br /> REMIT <br /> BASE EXPLANATION BILLING REMIT CE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE YO O <br /> LESS <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> OTHER - N <br /> OTHER <br /> Received b ate - -....Receipt No. .ter• —Permit No.. Issuance.Date Mailed .� Delivered <br /> y_.. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES s,– 1601,E.HAZELTON AVE.,P.O.Box 2009 57QCKTON,GA 95201 <br />