Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFF(CE USE: APPLICATION , <br /> .a (For Non-Transferable, Revocable, Suspendable) 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 witil San Joaquin County Ordinan a No. 1862 and khe rules a ndnaulations of the San J aquin cal Health District. <br /> Exact Site Address 4 l City/Town <br /> Owner's Name Phone <br /> Address t, City q <br /> r 'License '�// Business Phone E \3 <br /> Contractor's Name ®, <br /> Contractor's Address Emergency Phone i• �` r'�3 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No t <br /> TYPE OF WORK (CHECK): NEW WELLP(" DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ V r <br /> DISTANCE TO NEAREST: Septic Tank .S� ,-t Sew-,r Lines /4- Pit Privy <br /> Sewage Disposal Field Cesspool/seepage Pit Other <br /> Property Line/0;4- Private Domestic Well,/U Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 2. <br /> / <br /> DOMESTIC/PRIVATE <br /> ❑ DRILLED Dia. of Well Casing <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION V GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION JZ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information '1 <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 <br /> I.hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County V i <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 employ any person in such manner as to become subject to workman's compensation laws of California."- <br /> Contractor's hiring orsub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued,'l shall emplo p ons subject to workman's compensation laws of California." <br /> I wi call for7"tt <br /> pe orior to grouting and a final inspection. <br /> Signed XTitle: /� - Date: 451, <br /> (Draw Plot Plan on Rev a Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I2A 2 <br /> Application Accepted y Date <br /> Additional Comment : <br /> Ph se I Grout Inspection Pf,psA til Final Inspection <br /> Inspection By Date ^- Inspection By L— C— 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 <br /> LESS ! 3 <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ' 5_S <br /> Received by Date - Receipt No. - Permit No. - Issuance Date Mailed Delivered - I <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,GA 95291 <br />