Laserfiche WebLink
F Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OF,EICE USE: Ii APPLICATION <br /> `= (For Non-Transferable, Revot;able, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) I WATER QUALITY <br /> Application is hereb/made to the San Joaquin Local Health Districtfora 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 rules and regulations of the San Joaqujn Local Health District. t <br /> Exact Site Address cp%.Jr , ea Ae�,d City/Town P�l Y� � <br /> Owner's Name -a e • A P, s 0 7'7' ( Phone <br /> Address t"t. r City C c <br /> Contractor's Name License#' a Business Phone eK4;;K LA <br /> Contractor's Address Emergency Phone ��3 <br /> r Is Certificate of Workman's Compensation Insurance n File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> i <br /> DISTANCE TO NEAREST: Septic Tank &a Sewer Lines J%.A ti '/e Pit Privy r <br /> Sewage Disposal Field ua Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Welles Public Domestic Well /Z.t� -/ <br /> i INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL_ ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE i� ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC I) ❑ DRIVEN Gauge of Casing <br /> P'IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION I� ❑ ROTARY Type of Grout T N <br /> ❑ DISPOSAL OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: 1/I <br /> PUMP INSTALLATION: �� Contractor N,C <br /> Type of Pump sr H.P. <br /> PUMP REPLACEMENT: II! ❑ State Work Done <br /> PUMP REPAIR: H ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> I� Describe Material and Procedure <br /> lig <br /> II ,U <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,rand 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 /> l 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 /> =4v_1 <br /> for a Grout Insp prior to grouting and a final inspect' <br /> Signed X �-/�+1 Title Date: <br /> U (Draw Plot Plan on Reverse Side) <br /> ii <br /> E <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I II � � <br /> Application Accepted By Date <br /> — <br /> Additional Comments: 'ce <br /> n <br /> Phase II Grout Inspection P.has anal inspection pp / <br /> Inspection By Date Inspection By o G Date <br /> P _ <br /> Fee Is Due: ❑ ANNUALLY II ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 R Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASED EXPLANATION AMOUNT DUE CHECKED <br /> /DATE DATE REMITTED AMOUNT <br /> FEE If `'f\ y r <br /> F <br /> LESS <br /> I PRORATION .I <br /> PLUS ll <br /> PENALTY <br /> OTHER <br /> I OTHER <br /> SII <br /> is <br /> it 315 <br /> Received by Date,r Receipt No. Permit No. Issuance Date Mailed Delivered <br /> ) APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E:HAZELTON AYE.,P.O.Bois 2009 STOCKTON,CA 95201 <br />