Laserfiche WebLink
f <br /> Applications Will Be Processed When Submitted Properly Completed.Hesure <br /> '- <br /> FORAPPLICATION 1.OFFICE USE: <br /> (Fpr Non-Transferable,Revocable,Suspendable) � P.Li NW p <br /> ENVIRONMENTAL HEALTH PERMITr <br /> WATER QUALITY, 5 .jf? { ; <br /> (COMPLETE IN TRIPLICATE) . ~ <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 rules and regulations of the San Joaquin Local Health District. <br /> An z <br /> Exact Site Address F 1 F Q� R f 4ity/Town <br /> 1S4�s 4 <br /> Phone . <br /> Owner's Name 0? mAzitma <br /> ., City a <br /> Address 14 <br /> Contractor's Name License#,7$�, Business Phone <br /> Contractor's Address <br /> �, p �� !' —pT' 7-' h ° "'' y"Emergency Phone <br /> q ���_ � g q> <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ 'DESTRUCTION❑ <br /> W ION ❑ WELL ABANDONMENT El OTHER 11PUMP INSTALLATION❑ UMP REPAIR r <br /> EPLACEMENT <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 /> INTENDED USE _ TYPE OF WELL <br /> ❑ IND AL '❑ CABLE-TOOL Dia. of Well Excavation <br /> Ak_OOtAESILCLPtf�/ E 11 DRILLED <br /> Dia. of Well Casing' _ <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 11 GRAVEL PACK£ ; <br /> 11 RRIGATION Depth of Grout Seal <br /> + <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER ( Other Information <br /> [I GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> El State Work one 1 <br /> PUMP REPAIR: _D <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> rDescribe Material and Procedure <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance-with San Joaquin County r.. <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." i <br /> 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." r f <br /> I will call for a Grout Inspection prior to grouting and a final inspection. ` <br /> Signed XTitle: <br /> 3 <br /> ` Date: <br /> (Dra Plot Plan on Reverse Side} - <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I r �0--D Date <br /> Application Accepted By <br /> Additional.Comments: , <br /> Phase II pr u Inspection ' <br /> ase IIT a ection <br /> Inspection By r— Date Inspection ay <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ,❑ January 1 &Received By January 31 ❑ July i &Received 8y July 31 <br /> 'REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ -AMOUNT DUE CHECKED <br /> DATE DATE REMITTED t AMOUNT <br /> FEE y _ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> r T <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. -I sduance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 <br />