Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be o Sign The Application. LJ <br /> FOR OFFICE U E:'" APPLICATION APR 9 1980 . <br /> (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SAN JOAQDIfVp AL <br /> �� S TIER QUALITY 70 � HEALTH DISTRICT <br /> (COMPLETE IN TRIPLICATE) //�� f� <br /> Application is hereby made to the SdnJoaquin Local Hea h I ermittoconstruct a d/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 an the rules a d regulations of the San Joaquin Local Health District. <br /> Exact Site Address Lt./ 60&W&t✓ 0,,OZ.-�� f,,460C )4l&fy/Town AVLAQ_iN; f C* <br /> Owner's Name Phone v <br /> Address >_V City <br /> Contractor's Name �✓ t^t� License# Business Phone fo�«��! <br /> Contractor's Address O r+} Emergency Phone 5A �• <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yeses No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> i 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 ti <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL rface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Yd�� <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 />'k 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 /> 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 vfik call for a Groto grouting and a final inspe tong/ \ <br /> Signed X Title: Dateq� �� <br /> (Draw Plot Plan on Reverse Side) <br /> i FO DEPART ENT USE ONLY <br /> PHASEI <br /> Application Accepted By ALDate Q <br /> h Additional Comments: <br /> Phase II Grout InspectionP I Final Inspection <br /> Inspection By Date Inspection By Date ` <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE El'EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE F•�� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> �n la oo a_ as3 <br /> Received by Dati Receipt No. Permit No, Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 95201 <br />