Laserfiche WebLink
Applications Will Be Proce ed WheSubmitted Properly Completed. Be Sure To Sign The Application, <br /> PPN <br /> FOR OFFICE USE: fiyPi.'IErA _ <br /> (For Non Fart ferable; ReY4C ble Susper 8ble) PU&v E,WELL <br /> 01-T ENVIRONFAENTA� HEALTH PEF3M' <br /> _ _ f;: <br /> (COMPLETE IN TRIPLICATE) WATER�Mtl ` '_ <br /> Application is hereby made to the San Joaquin Local Health Dist0pr a.{tgrmit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No 18 2 anti t ie rt�il6tpril ,TQulations of the San aquin Local Health District. <br /> Exact Site Address ` , City/Town - <br /> ` f 1 - -- --� -- <br /> Address nAip .u� _ Phone ` <br /> Owner's Name � e.. <br /> �.1rn IC�I.+.r./ i=�;K. City—::: _r' <br /> Contractor's Name License#/6 %x Business Phone_- . <br /> Contractor's Address /` ..-7`7 `L Emergency Ph <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No X <br /> TYPE OF WORK (CHECK)- NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 4 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑� PUMP REPAIR❑ <br /> REPLACEMENT❑ `'n' <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 /> I]ADUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> El DOMESTIC/PRIVATE ❑ DRILLED pia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Sea! <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 /> PUMP REPLACEMENT: If State Work Done 42_�_r.... y <br /> PUMP REPAIR: ❑ state Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth _ <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 4 <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 call for a Grout Inspection prior 10 grouting and a final inspection. <br /> Signed X J t �_ � Z i�{s Title: '• �.. a. <br /> Date: <br /> (Draw Plot Plan on Reverse Side, <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By Date j~ <br /> Additional Comments:- � <br /> Phase 11 Grout Inspection Ted' III Fin Inspection <br /> Inspection By Dater Inspection By '+ z` �� Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Recuary 31 ❑ July 1 g Received By Jury 31 <br /> BASE EXPLANATION BILLING REMIT <br /> REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> 1I <br /> FEET <br /> LESS — _ <br /> PRORATION j <br /> PLUS - - - <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No Issue Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITJSERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />