Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. BeSureTosign Tnerapilrhgn. <br /> FOR oFFlce USE: APPLICATION . 7 <br /> (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 wit an Joaqui Ordinance No. 1862 and nt e rl„�I_2$ iV' regulations of the San Joaquin Local Health District. <br /> Exact Site Address ��CotoN �K e (F49J..b- AJ- City/Town p �/ <br /> Owner's Name \bqsir Phoned <br /> Address D Ev!r City cK-fid oc/' GCS. <br /> Contractor's Name i- License Ie Business Phone - u 3y <br /> I Contractor's Address Emergency Phoneoq��iz Z4,— <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes _ No <br /> TYPE OF WORK (CHECK): NEW WELL RI-' DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 0--_PUMP REPAIR <br /> REPLACEMENT❑ <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 Weil <br /> INTENDED USE TYPE OF WELL r� <br /> ❑ I��STRIAL 11 CABLE TOOL'' Dia. of Well Excavation <br /> l�DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> € 11GRAVEL PACK Depth of Grout Seal <br /> ❑ IRRIGATION P \ <br /> ❑ CATHODIC PROTECTION &OARY Type of GrouterC C <br /> ❑ DISPOSAL ❑ OTHER Other Information ` <br /> ❑ GEOPHYSICAL - urf ce Seal Instal d By: .. ' <br /> - R <br /> I PUMP INSTALLATION: Contractor /IE <br /> Type of Pump d' H.P. <br /> PUMP REPLACEMENT: i ❑ State Work Done <br /> C PUMP REPAIR: ❑ State Work Done <br /> p DESTRUCTION OF WELL: Well Diameter- - Approximate Depth <br /> F 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 /> 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." <br /> Contractor's hiring or sub-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 /> 1 will call for a Gra t ti p r to grouting and a final inspection. <br /> Signe. . Title: CcP�1`f' r Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR D PARTMENT USE ONLY PHASE I f/77 <br /> Application Accepted By Date <br /> Additional Comments: <br /> I Phase II Grout Inspectl. n�kC lqa! S/d hase III Final Inspection <br /> Date Inspection By Daze �2 <br /> . Inspection By _ ... <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE F ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING <br /> � BASE s EXPLANATION BILLING. REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION - <br /> e <br /> PLUS ± } <br /> PENALTY <br /> 4 <br /> OTHER t <br /> ,I <br /> OTHER <br /> _ --. - Is uan e Datd Mailed Delivered - - <br /> Received by Date Receipt No. Permit No. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />