Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be SµreT , i Application. <br /> FOR OFFICE USE: APPLICATION <br /> � ,t� <br /> (For Non-Transferable, Re I�,,�'S$ eii�a e) <br /> ENVIRONMENTAL H TH PERM jT �gg1 <br /> (COMPLETE IN TRIPLICATE) WATER QUA PUMP&WELL <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or instal ld-,');A6ein described.This application is <br /> made in compliance with SanJoaquin County Ordinance No. 1862 and the rules antlatiens �lu'n Local Health District. <br /> Exact Site Address -051' Ltl, `", !Town - <br /> r+ ofQ r� <br /> Owner's Name A- ,`f o L t+ of Phone <br /> Address A 3 City A: C-v <br /> Contractor's Name License#/(- )-3,23 Business Phone d t <br /> Contractor's Address r Emergency Phone _ C-�t- (t. <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_ +./ No d <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR®� <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 /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> Cl <br /> iUOMESTIC/PUBLIC C1DRIVEN Gauge of Casing <br /> rr 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. :2,r ! <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done ` <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure -1 <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 r <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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> Icall or a GroIn I ction prior to grouting and a final inspection. J <br /> Signed XTitle: _- /� Date: + <br /> (Draw Plot Plan on Revere 4ide) A <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _ _ <br /> I 1 <br /> Application Accepted By P �- Date <br /> Additional Comments: - <br /> Phase II Grout Inspection Phase/III Final Inspection Q� <br /> Inspection By �� Date Inspection By Date 'v/ <br /> L z <br /> Fee IS Due: ElANNUALLY El PER UNIT PER SITE 13 EACH El January 1 8 Received By January 31 ❑ July July 1 1 8 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> �3 <br /> Received by Date Receipt No. Permit No. Issuancb Datb Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O,Box 2009 STOCKTON,CA 95201 <br />