Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
Applications Will Be Processed When Submitted Properly Completed. ByeToSignTheAppuca lone j <br /> FOR OFFICE USE: I APPLICATION SEP .271979 _ <br /> (For Non-Transferable, Revocable, Suspendable) P g,WELL <br /> ENVIRONMENTAL HEALTH PE SAN JOAQUIN Lilt;�L ; <br /> HEALTH DISTRICT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> 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 <br /> made in compliance with San Joaquin County Ordinan�e No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address��n Ip �SIJ�V !' City/Town s <br /> II <br /> Owner's Name VAJ Phone <br /> I :y <br /> Address City <br /> Contractor's Name M +- �� License#kalla _ Business Phone 'S�{ �� <br /> f Contractor's Address �� ir++ Emergency Phone � <br /> F Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> I TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> 1 WELL CHLORINATION ❑ WELL ABANDONMENT (] OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR®' <br /> 4 REPLACEMENT 11r I <br /> DISTANCE TO NEAREST: Septic Tank,W Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Pro0perty Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> r ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> p ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> f ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 0 <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information C(i <br /> 11 GEOPHYSICAL Surface Seal Installed By: ^� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. Z <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: <br /> ® State Work Done t4 D <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:"I certify that in the performance of the work for which this permit <br /> is issued, I shall not ermploy any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring orlsub-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 /> l <br /> r I wil for a Grou I spec', prior"to grouting and a final inspection - y <br /> Signed X Title: ,�� Date: <br /> a (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI _z - <br /> I Application Accepted By I Date �9 <br /> Additional Comments: If <br /> Phase II Grout Inspection s II! Final pection <br /> Inspection By �� Date Inspection By. tI- <br /> Fee IS Due: ❑ ANNUALLY I� ❑ PER UNIT 5 PER SITE ❑ EACH ❑ January t &Received By January 31 ❑ July 1 &Received By July 31 / <br /> Ii REMIT / <br /> BASLE EXPLANATION BILLING �REANCE AMOUNT DUE CHECKED <br /> Ip DATEREMITTED AMOUNT <br /> FEE <br /> 1 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER SII •� . <br /> OTHER !!! <br /> {, Iw ' <br /> Received by Date Receipt No. Permit No. Issuance Date, Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO. ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 20119 * STOCKTON,CA 95. <br /> 11 f <br />