Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> r%JR OFFICE USE: J - APPLICATION • -t <br /> At 0� (For Non-Transferable, Revocable,Suspendable) G � <br /> ENVIRONMENTAL HEALTH PERMIT / PUMP&WELL <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 Ordinance No. 1862 and the les and/re uiations of the San Joaquin Local Health District. <br /> Exact Site Address r }) /�}A�(9 sq ; oma i�rLe uerty/Town <br /> Owner's Name -filet_ a Phone <br /> Address -1 - i _,/�-11+d City— <br /> Contractor's Name � License# 1�'3 �Ys�Business Phone__ <br /> Contractor's Address -16-D �a Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on F'e With SJLHD? Yes_ �X No 7 <br /> TYPE OF WORK,(CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ `f� <br /> WELL CHLORINATION ❑ 'Wt_t NDONMENT ❑ OTHER ❑ PUMP INSTALLATION RI PUMP REPAIR❑ ' <br /> REPLACEMENT❑ <br /> DISTANCETO NEAREST: Septic Tank-- Sewer Lines Pit Privy <br /> Sewage Disposal F(efd !` Cesspool/Seepage Pit Other <br /> Property Line '� 3 Private Domestic Well Public Domestic Well <br /> INTENDED USE. TYPE OF WELL <br /> ❑ INDUSTRIAL ~~❑-�C-ABLE TOOL Dia- of Well Excavation <br /> ❑ <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC �~ ❑ DRI.V.EN Gauge of Casing—' <br /> IRRIGATION -❑ GRAVEL PACK Depth of Grout Seal Y <br /> ❑ CATHODIC PROTECTION_ ❑ ROTARY Type of Grout Y E <br /> ❑ DISPOSAL —❑'OTHER Other Information <br /> ❑ <br /> GEOPHYSICAL-`-,..'- Surface Seal Installed By: 11 W 4 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. S' - j <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP : 19 State Work Done Z �, r ♦ o A <br /> DESTRUCTION OF WELL: Well Diameter Ap(roximate Depth i <br /> Describe Material and Procedure <br /> " k <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. I <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 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 ill call for a Grout Inspecr pri t grou ' g a final inspection. <br /> Signed X Title: Date: l� <br /> (Draw Plo Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY r <br /> PHASE I ��•�.Y11./ <br /> Application Accepted By Q0.^- Date ^�a <br /> Additional Comments: 01 <br /> Phase 11 Grout Inspection Phase III Final Inspection <br /> Inspection''By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY El UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 July 1 &Received-By July 31 <br /> o B#LLING REMITTANCE $ REMIT <br /> BASE EXPLANATION PATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE s� <br /> LESS f <br /> PRORATION <br /> PLUS'.` Z, <br /> PENALTY <br /> -OTHER <br /> Q OTHER <br /> / <br /> Received by pate Receipt No. Permit No. - Y Issuance,Date MailedDelivered ! <br /> APPLICANT—RETURN ALL COPIES TO:' ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 200 STOCKTON,CA 95201 <br />