Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
! Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> )`A OF�CE USE: / <br /> APPLICATION <br /> ( w] ed /e 0 (For Non-Transferable,Revocable, Suspendable) <br /> iPUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> !1: U - <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 County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address S IllR;!fto °✓ 19& l City/Town <br /> Owner's Name O +'�•G. Phone <br /> I il <br /> Address 5— Al zS City <br /> Contractor's Name s J`O"rJ 4PI/ se,. License#I!?a 7 Business Phone — 6 �1 tr <br /> Contractor's Address If Emergency Phone <br /> Ise Certificate of Workman's Compensation Insurance on File With SJLHD? Yes _ No <br /> TYPE OF WORT( (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION C] WELL ABANDONMENT 11OTHER ❑ 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 <br /> ' INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> I.. DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> i <br /> CATHODIC'PROTECTION ❑ ROTARY Type of Grout <br /> DISPOSAL ❑ OTHER Other Information <br /> y GEOPHYSICAL Surface Seal Installed By: ` <br /> r PUMP INSTALLATION: Contractor !e t ` Zwo <br /> Type of Pump Se..tf' .,...e.�s^, �/� H.P. <br /> UMP REPLACEMENT: ® State Work Done i&*, r ?A1g <br /> PUMP REPAIR: ❑ State Work Dane <br /> i l7ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> 1 Describe Material and Procedure <br /> k 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 regulationsof the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> t is issued, l 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 /> lwil call for a Grout Inspe ti io to rou g,,and final inspection. <br /> Signed X — itle: � Date: <br /> (Draw Plot Ian on Reverse Side) <br /> I FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By �% ?""�^ 4' bate` <br /> Additional Comments: <br /> Phase II Grout Inspection ,P,�seIII Final Inspection ` <br /> Inspection By Date Inspection By__ ate' U <br /> j. <br /> e '// r <br /> Fee Is DUB: 11 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 8 Received By Juiy 31. <br /> REMIT <br /> BASE EXPLANATION 'BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> i PRORATION - <br /> F <br /> PLUS <br /> I' PENALTY <br /> OTHER <br /> li <br /> �i OTHER <br /> k © 5 � EaB <br /> Received by "Date Receipt No. Permit No. Iss lance 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 />