Laserfiche WebLink
IrAQplicatio`ns Will Be Processed WhenSubmitted ProperlyGompletea o ..T-. , �• --rr••- <br /> FOR OFFICE USE: <br /> ONS �, 11J. 1U1 <br /> (For Non-Transferable, Re 1t <br /> ale) <br /> - PUMP&WELL <br /> ENVIRONMENTAL TH PERNV �g�O <br /> (COMPLETE IN TRIPLICATE) WATER QU b <br /> �' Cn1 A erein described.This application is <br /> Application is hereby made to the'San Joaquin Local Health District for a permitto construct and//o i�"hAaroe RP <br /> i made in compliance with San Joaquin County Ordinance No. 1B 2 nd the rules anrtjlla�lt�tt f quin Local Health District. <br /> Exact Site Address O I 1�t Town <br /> I� Phone <br /> Owner's Nariie p <br /> c I City <br /> Address x, <br /> Contractor's Name License # 32t Business Phone <br /> Contractor's Address 3 S. r- ea Emergency Phone <br /> Is Certificate of Workman's Compensation to urance on File With SJLHD? Yes No <br /> TYPE OF WORK {CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ SWELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ :1 <br /> I Sewer Lines �'� Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank <br /> 00 <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well l <br /> I INTENDED USE TYPE OF WELL <br /> ❑ NDUSTRIAL 11 CABLE TOOL Dia: of Well Excavation <br /> eOLMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION GRAVEL_ PACK Depth of Grout Sea ,. <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout 'R <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> +,D ` <br /> ❑ GEOPHYSICAL ' Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> z <br /> PUMP REPAIR: C] state Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> 1 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 /> Y' <br /> Contractor's hiringl1or sub-contracting signature certifies the following:'9 certify that in the performance of the work for which this <br /> permit is issued, l shall employ persons subject to workman's compensation laws of California." <br /> h ` <br /> I wit r a Gr ut Ins on prior Io groutin and a final inspection. <br /> f Signed X Title: Date: <br /> raw Plot Plan on Reverse Side} <br /> 1 . <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 0 Date iv-`1li-Q0a <br /> Application Accepted By <br /> Additional Comments:., <br /> Phase II Grout Inspection Phese Ilk Final Inspection <br /> Inspection By ,r, Date Inspection By Date <br /> f Fee 15 Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 i Received By January 31 ❑ July. &Receiv REMIT <br /> d By u1y 31 <br /> IM BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> i3 . <br /> FEE <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER' 4. _ <br /> • Received byII Date Receipt No. Permit No. —I ante D to Mailed Delivered <br /> APPLICANT—RETURN•ALL COPIES TO:. ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E. 95201 <br /> HAZELTON AVE.,AYE.,P.O.P.O.'Boa 2009 STOCKTON,-G <br />