Laserfiche WebLink
ApplicationsWill Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <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 J aquin Countyprdina <br /> Exact Site Address nce No. 1862 nd a rules and regulations of the San Joa uin Loca Health District. <br /> / <br /> City/17f9GYm �� llEs <br /> Owner's Name G' ! ( S <br /> Address Phone <br /> Contractor's Name , cam /" City <br /> License L Business Phone e i <br /> Contractor's Address 3 <br /> Is Certificate of Workman's Compensation in Emergency Phone <br /> ance on File With SJLHD? Yes__ r No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTIONE] <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION yrs pUMp REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank # <br /> Sewer Lines__._��� � Pit Privy <br /> Sewage Disposal field Cesspool/Seepage Pit �Q� , <br /> Property Line Private Domestic Well ' �-- Op�her <br /> INTENDED USE Public Domestic Welt <br /> ❑ INDUSTRIAL11� <br /> OF WELL <br /> DOMESTIC/PRIVATE ❑ CABLE TOOL Dia. of Well Excavation <br /> �ILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ��uy{ <br /> ❑ DRIVEN Gauge of Casing <br /> 11 IRRIGATION ❑ C,gAVEL PACK <br /> 11 CATHODIC PROTECTION ©rROTARY <br /> te Depth of Grout Seal <br /> 11DISPOSAL Type of Grout <br /> 11 GEOPHYSICAL �— <br /> ❑ OTHER Other Information <br /> PUMP INSTALLATION: Contractor /Surf c eal Installed By: <br /> Typa,I ptyimp H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done — <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I ha ie 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 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 /> 1 tit call for a G n tion prior to grouting and a final inspection. <br /> Signed e- <br /> t Title: A `/ <br /> (Draw Plot Plan on Revers Side) per Date: <br /> PHASEI FOR DEPARTMENT USE ONLY <br /> Application Accepted By <br /> Additional Comments: Date_ <br /> a e I Grout Inspection <br /> Inspection By P,�s�epIIFI Final Inspection <br /> Date Inspection B RIM� � <br /> Date <br /> Fee IS Due: 11 ANNUALLY PER UNIT ❑ PER SITE <br /> ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE AMOUNT <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by ' Date Receipt No. ✓� <br /> Permit No. Is uan a Date <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES Mailed Delivered <br /> - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />