Laserfiche WebLink
Applications Will Be Processed When SubmittedProperlyCompleted. seSure TOsign IneAppncauon. <br /> FOR OFFICE USE: APPLICATION <br /> For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE iN TRIPLICATE) I WATER QUALITY z.2- - 430 ZY <br /> Application is hereby made to the San Joaquin Local H,701Districtforapermittoconstructand/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No.1862 ant the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address .. •�.i i �r1 01'�'"T t Zk Vdty/Town rf rpt » fZ f <br /> Owner's Name 1� I� 13z, 4z !i! Phone57 x a== �- <br /> Address fJ 677 A =� � � � � �*� � �� City <br /> License# _nr�7� f1 1 Business Phone (17 <br /> Contractor's Name <br /> Contractor's Address p y l� y x Emergency Phone :J '� ` TY <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 3 <br /> Z71 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 11 Ill <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ s <br /> DISTANCE TO NEAREST: Septic Tank ,Sewer Lines—� " Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Pr'o,piertyrLine_ - - =Pri.vate;_Domestic Well Public Domestic Well <br /> INTENDED USE TYPE`OF WI`LL i <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ® DOMESTIC/PRIVATE ❑ DRILLED i Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> t <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth)of,Grout Seal <br /> ^� <br /> 11 CATHODIC PROTECTION 11 ROTARY ) Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Othet_Information <br /> ❑ GEOPHYSICAL � Surface Seal Installed By: n' <br /> PUMP INSTALLATION: Contractor 1, C" 'z)^_ <br /> Type of Pump t J H.P. J <br /> PUMP REPLACEMENT: I ❑ State Work Done <br /> PUMP REPAIR. ,State Work Done �04 <br /> DESTRUCTION OF- WELL:` � ' Wgil Diameter Approximate Depth <br /> Describe Material and Procedure (11 <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,!Cand rules and regulations of the San Joaquin Local Health District. t` <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 riot 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 /> I ill call for a Grouspe lion prior to grouting and a final inspection. t, x t. T <br /> Signed X c ... Title: ,,'- �. f. i Date., f 1 <br /> E I` (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> F <br /> Application Accepted By Date <br /> Additional Comments: l� <br /> r <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By �M Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> i REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> �EE ,1P f ` <br /> RATION <br /> PLUS tl <br /> PENALTY R <br /> OTHER I� <br /> OTHER <br /> t. '� <br /> Received by Date Receipt No. Permit Na. Issuance Date Mailed Delivered <br /> STOCKTON,CA 45201 <br /> . .APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2004 <br /> s Ij <br />