Laserfiche WebLink
a1n(d�i kte r;;sl a Submitted Properly Completed.Be Sure To Sign The Application. <br /> I ►� <br /> WR OFFICE USE: -'= L l� APPLICATION <br /> (For ransferable, Revocable,Suspendable) PUMP&WELL <br /> AUG 2J6 18INVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRWLICAT i i+, i CA WATER QUALITY <br /> Application is hereby madetothr_SA�Jj9u � hDistrictfora permit install thew h eindescribed.Thisapplication is <br /> kil=. _ tt P <br /> made in compliance wit q n Count rdin ce 1 62 and th rules and regulations of the Sa oa in Lo al H alth Di rict. <br /> Exact Site Address `(/@ e. g City/Town <br /> Owner's Name lr Phone <br /> Addressa City - l <br /> Contractor's Name . License# l �,�373 Business Phone 4 b <br /> Contractor's Address Emergency Phone ' A4(a (a 9) 10 7 V <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X, No _ <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 1 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑- PUMP REPAIR❑ 6_ <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 /> ❑ 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 tion <br /> ❑ GEOPHYSICAL Surface Seal n tailed By: <br /> PUMP INSTALLATION: Contractor Q.. <br /> Type of Pump 6 1P. <br /> PUMP REPLACEMENT: State Work Done Ir <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> i <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 is , sha t employ any person in such manner as to become subject to workman's compensation laws of California." <br /> ntractor's hiring r sub-contracting sig re certifies the following:"I certify that in the performance of the work for which this <br /> ermit is is ued, hall empio er on sub' ctto wooTk <br /> _jpan's compensation laws of California." <br /> I will C f rout Ins ti p o uting a a final inspect' <br /> , ,f � S-2,4Signed X Title: xpw Date: —f <br /> / <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By ` Date LC o2�—F�1 <br /> Additional Comments: <br /> Phase II Grout Inspection. Phase III Final inspection i <br /> Inspection By— Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE y,_❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ - <br /> BASE EXPLANATION � -�� AMOUNT DUE- CHECKED <br /> DATE DATE REMITTED + AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 13 [09 73 ) � II <br /> Received by Date Receipt No. Permit No. Issuance Qat--e I Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95211111 <br />