Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> 'fes_ 6TFICE 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 madetotheSan Joaquin Local Health Districtfora permit to construct and/or install thework herein described.This application is <br /> made in compliance with n Joaquin County Ctrdi nce No. 1862 d the les and regulations of the San oa uin Local Health District. <br /> Exact Site Address �s 1.E�t �.� - rL { AV E-� /!7� �� City/Town,(+��T6��rokz <br /> Owner's Name TgPhone 'i !3 -0-50(3 <br /> Address I� b� D City LA3 <br /> Contractor's Name CL WE L Q a T License#_A7.1 s100 Business Phone <br /> Contractor's Address %07-4t• y Emergency Phone Z�s <br /> Is Certificate of Workman's Compensation Innsur on File With SJLHD? Yes L./ No <br /> TYPE OF WORK (CHECK): NEW WELL EaDEEPEN ❑ 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 '� �d <br /> ❑ I 11USTRIAL CABLE TOOL Dia. of Well Excavation__ <br /> R DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION 11 GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION C�oTARY ' Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface!eal In-51alled By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <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 <br /> I hereby certify that I have prepared this application and that the work will be done-in accordarice with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Hgalth,Dietrict <br /> Homeowner or licensed agent's signaturecertifies 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 work men's"compen sation laws of California." <br /> aw <br /> actor's hiring or sub-contracting signature certifies the following:"I certifyythat in the performance of the work for which this <br /> t is issu I shall empl perso s subject to workman's compensation laws of California." <br /> call for a Lit In t prior grouting and a final inspection. TSA e 'Al <br /> Signed X Title: h�e.�..-1■t" 0_0 Q Date: �+ �&"Iy <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I (� <br /> Applicatiow-•Accepted By Com, e _M.__.... Date <br /> Additional Comments: <br /> Ph a 11 l Lit Inspection Phase III Final Inspection <br /> Inspection Byl, Date s "�" Inspection By Date____ <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 /> l.� AMOUNT <br /> FEE I 4 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Pate I Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />