Laserfiche WebLink
- Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR FICE 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 made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin Coun y Ordin e�r. 1862 and the rules and regulations of the San Joa Jin Loki-Health District. <br /> Exact Site Address �, A ��iY�42IN City/Town Lt"J�/`�6'a <br /> Owner's Name Phone <br /> Address city <br /> Contractor's Name &,Aq License#&WIV Business Phone ".,- ,?16 <br /> Contractor's Address Emergency Pho e C 1 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No 1 <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR Jt <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank /60 /Af $ewer Lines Asn Pit Privy _ J-� <br /> Sewage Disposal Field :«G -� Cesspool/Seepage Pit Other <br /> Property Line/6 Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 4� <br /> ^DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing it ,n <br /> ❑`DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing �{� <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout X At <br /> ❑ DISPOSAL ❑ OTHER Other Information m <br /> ❑ GEOPHYSICAL Surface Seal Installed By: t <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 accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> r <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-contractin),ignature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued I shall mploy r ns subject to workman's compensation laws of California." <br /> �I, call for a rou spect' `ior to grouting and a final inspection. III <br /> V Signed X Title: Date: <br /> (Draw Plot Plan on Reverse e) <br /> FOR DEPARTMENT USE ONLY 1 <br /> PHASE t <br /> s' o <br /> "rApplication Accepted By� / �T �� Date 7 �Q <br /> Additional Comments: <br /> ase I Grout spection '�� Phase III Final Inspection <br /> Inspection Bye Date Inspection By A4 Date <br /> .Fee Is Due: ❑ AN /LLY ❑ PER UNIT ❑ PER SITE - ❑ EACH- ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION, DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> ~FEE <br /> 13 <br /> J 7 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN-ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601-E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 { <br /> 1 <br />