Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> rr (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 fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San JoaquinCpunty Ordinan a No. 186 and the rules and regulations of the Sa quin Local alth istrict. <br /> Exact Site Address . . City/To wn � � r1 <br /> � <br /> Owner's Name Phone `C%2-- 0\35 <br /> Address CA City <br /> Contractor's Name ` E' ;; License#' - Business Phone ti I <br /> Contractor's Address E. = ' ' ' `{ Emergency Phone ' <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes w No < I <br /> TYPE OF WORK(CHECK): NEW WELL❑' DEEPEN ❑ RECONDITION❑ ' DESTRUCTION❑ f <br /> WELL.,CHLORINATION.❑ WELL-ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ .' , -J + <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other ti <br /> Property Line Private Domestic Well Public Domestic Well i <br /> INTENDED USE TYPE OF WELL I <br /> 1 <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ,W DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION "❑ GRAVEL PACK -' ' be-p'th 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 ...ka H,P, -k 1 . <br /> PUMP REPLACEMENT: ❑ State Work,Done--- -i*_ ! <br /> PUMP REPAIR: ❑ Stat Workt,DoneLA <br /> ) <br /> DESTRUCTION Of WELL: Well Diameter Approximate Depth <br /> / gescn Material and Procedure <br /> I hereby certify tha I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> r ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> r Home owner 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." 3 <br /> 3 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 I II for roul Inspec n=gra g and a final inspection. <br /> f <br /> Signed Title: mat-.rig Dater_ <br /> (Draw P of Plan on Reverse Side) <br /> - r <br /> �` <r FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments, t <br /> T Phase It Grout Inspection _ s III Final nspection p <br /> Inspection By y Date.. Inspection By Date <br /> Fee Is Due: ElANNUALLY PER UNIT ti,`0,'PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received Ry July 31 <br /> Y �-r `BILLENG "REMITTANCE $ REMIT <br /> BASE•-- :. EXPLANATION w AMOUNT DUE CHEGKED r <br /> DATE DATE REMITTED AMOUNT <br /> FEE r 'J O <br /> LESS <br /> PRORATION <br /> PLUS''• <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by bate I, Receipt No. Permit No. -Issuance Date .Mailed Delivered. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1.601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 i <br />