Laserfiche WebLink
} Applications Will Be Processed When Submitted Properly Completed. Be sureToSignTneAppncallon. <br /> FOR OFFICE USE-' / , APPLICATION <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 with San Joaquin County Ordinance No. 1862 and the rules anq regulations of the San Joaquin Local Health District, <br /> Exact Site Address <br /> City/Town <br /> Owner's Name Phone <br /> Address City <br /> Contract 's e Lic <br /> orNamnse# Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With JLHD? Yes__ � No 0 <br /> TYPE OF WORK (CHECK): NEW WELL 11DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR �1 <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 Well <br /> I INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> fE ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> " ❑ IRRIGATION ❑ GRAVEL PACK Depth 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 H.P. <br /> I PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP 00""llip; AR State Work Done T <br /> 1' DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> i 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 /> Homeowner or licensed agent's signature certifies the following."I certify that in the performance of the work for which this permit <br /> f :is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> y Contractor's hiring or sub-contracting signature certifies the following:1 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 /> 1 '1 call for a Grout Inspection p t r in Kd o f al inspection. <br /> Signed w _ Date: <br /> r <br /> raw Plot PI on Reverse Side) <br /> r <br /> FOR DEPARTMENT USE ONLY !! <br /> PHASE I `� ' 0"�b4o <br /> Application Accepted By tom .• Date <br /> Additional Comments: <br /> Phase 11 Grout InspectionPhase III Final Inspection <br /> j Inspection By Ml o� Date _ inspection By Date <br /> vFee 15 Dile: ❑ ANNUALLY 0 PER UNIT ❑ PER SITE t ❑'EACH ElJanuary 1 &Received By January 31 ❑ July 1 &Received EMITBy uly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> 4 <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> t <br /> OTHER <br /> lipReceived by Date Receipt No. Permit No. ssu ce D to Mailed Delivered <br /> ' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA2ELTON AVE.,P.O.Box 2009STOCKTON,CA 9 <br />