Laserfiche WebLink
ApplicationsWill Be Processed When Submitted Properly Completed. 8e Sure To Sign The Application. <br /> 6 F""1i R OFFICE USE: APPLICATION <br /> f /ell (For Non-Transferable, Revocable, Suspendable) J f <br /> ENVIRONMENTAL HEALTH PERMIT i PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) ., WATER QUALITY <br /> etothe an Joaquin is hereby mad ca eat isrlct oaper itto'constructand/or <br /> install the work herein described.Thisapplication is <br /> made in compliance wi San Joaquin County Ordinance No. 1862 and the ruled <br /> Exact Site Address 0 o <br /> re ul tions f the San Joaquin Local Health District. <br /> e � <br /> City/Town <br /> Owner's Name <br /> Phone <br /> Address City <br /> Contractor's Name License# 3 �'� Busin�sPne Y ��4;-�?7;7K <br /> Contractor's Address Emergency Phone '-�- <br /> Is Certificate of Workman's Compensation Insurance on FWith SJLHD? Yes_X No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEP E ❑ RECONDITION❑ DESTRUCTION❑ <br /> j WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRJ� <br /> REPLACEMENT❑ G <br /> w.� <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 C1 DRIVEN Gauge of Casing <br /> IRRIGATION 1 ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> E] GEOPHYSICAL Surface Seal Install <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 4. <br /> I <br /> Describe Material and Procedure <br /> I s <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 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 1 w I call for a Grout Inspect! <br /> pri r t ro 'ng and a final inspection. l <br /> Signed itle: Date: <br /> (Draw Plot Ian on Reverse Side) <-�- <br /> i FOR-DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: ' <br /> Phase Grout Inspection Ph se III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY PER UNfT� ❑.PFR SITE ❑ EACH ❑ January 1 &Received By January 31 El July 1 &Received By July 31 <br /> BILLING REMITTANCE REMIT i <br /> BASE EXPLANATION <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE ; <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - ' <br /> OTHER <br /> OTHER + <br /> Received by Date - Receipt N. Permit No. - ' <br /> suan a Dae Mailed Delivered <br /> APPLICANT—RETURN ALL Coll TO; ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 it HAZELTON AVE.,Il Box 2009- STOCKTON,CA 95201 E <br />