Laserfiche WebLink
_Ap,licatiowts-� lit sd Pr66�es`eliI 'hen Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> FOR OFFICE U49. nn p, <br /> APPLICATION f <br /> (ail R u V 1y�> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> �°�1N jopQUIN LOCAL WATER QUALITY <br /> (COMPLETE IN TRIPLICLEILH DISTRICT <br /> Application is hereby ma a to the an Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joagcbin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District.. <br /> Exact Site Address 13 �J d& City/Town <br /> Owner's Names Phone y 3 <br /> Address ��' z9V City - " <br /> Contractor's Name > License# 7 Business Phone 9 S <br /> Contractor's Address 9 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL 0' DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ pR <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑__� PUMP REPAIR❑ 4J <br /> REPLACEMENT❑ tt� <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines 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 <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation <br /> O'DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <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 CIL <br /> 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:"I certify that in the performance of the work forwhich 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 /> Iwpill call for a /Grout Inspection prior to grouting and a final Inspection. <br /> Signed X Title: Date: <br /> 47 (Draw Plot Plan on Reverse Sids) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Q� �-- <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection P as III Fina Inspections 2. <br /> Inspection By1 Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE SCkQ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No Permit No. Issua ce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1&01 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9520 <br />