Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> "OFFICE USE: 1 APPLICATION <br /> P; (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP &WFLL <br /> (COMPLETE IN TRIPLICATE) //`�V[�- // � OO WATER QUALITY <br /> Application is hereby made to theSa�iJdacK L�I Health��lc f rapermittoconstructand/or install the work,herein described.This application is <br /> made in compliance with,5 n Joaquin Cou ty rdin nce No. t 62 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address N. <br /> 6� �- City/Town <br /> Owner's Name Phone <br /> Address 7 eCity- A"6V;%1 .�Q✓ <br /> Contractor's Name J5 icense#__:2Q)eU!3 BusinessPhon— l <br /> Contractor's Address Emergency Phone 3-6 <br /> Is Certificate of Workman's Compensation Insur a on File With SJLHD? Yes I_ No � <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ , <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank /7017e Sewer Lines 0/78 Pit Privy <br /> Sewage Disposal Field /1QL?e 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 /> L��DOMESTIC/PRIVATE ElDRILLED Dia. of Well Casing 6 /Q 1 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ��n a) <br /> ❑ IRRIGATION ❑+GAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION Mo<O'TARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed 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 accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of 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 /> 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 s issued, i shall a loy persons subject to workman's compensation laws of California." <br /> I will atl for a Gro t s ction prior W grou 'ng an f'n&icn. <br /> Signed X Date: alo2 <br /> (Draw Plot Plan on Reverse 5i ) J ' <br /> FOR DEPARTMENT USEONLYt <br /> PHASE <br /> Application Accepted By Date 4 <br /> Additional Comments: <br /> Phase II Grout Inspection 9 s I final Inspection - <br /> Inspection By DateInspection By Date <br /> Fee Is Due: ❑ ANNUALLY -❑ PER UNIT PER SITE ❑ EACH ❑ January l &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED RMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS — <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER " <br /> Received by ate Receipt No. Permit No. Issuance Date Mailed - Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.NAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 - <br />