Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> FOR OFFICE USE: ( _ APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto 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 rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 3 v��. I14714C.1dd/W A '` d City/Town�4_► �.�eq to Q <br /> Owner's Name Phone J 59 9 <br /> Address ./� 1/34 City 'J <br /> r <br /> p�f� S <br /> Contractor's Name License fpc Y O LtiVSBusiness P _� le 9 C� l f <br /> Contractor's Address A, �c t�s�L-e® Emergency Phone 3 z" IGhone�l�2 <br /> Is Certificate of Workman's Comp e 'ation Insurance on File With SJLHD? Yes 4- No <br /> TYPE OF WORK (CHECK): '-KEW.WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ (� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT Q <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field_ Cesspool/Seepage Pit Other <br /> Property Line /'!s! Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation M f 2 (� <br /> 9�OMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing f? <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal G' <br /> ❑ CATHODIC PROTECTION 91-�TARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Insttalll�q By: ,,✓ <br /> PUMP INSTALLATION: Contractor <br /> TH.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> ION OF WELL: Well Diameter '* Approximate Depth �� f <br /> 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 /> 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 will c fora Grout Inspection prior to and a final inspection. <br /> Signed X .. a-� , Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date ��� � <br /> Additional Comments: <br /> Ph a rout I pection ',/P,hhpe Final pection , <br /> Inspection By ''t� ate 2 � Inspection By�n�i� atek <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE � �^p rr�� AMOUNT <br /> Ob d0QQ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> f <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />