Laserfiche WebLink
Applications Will Be Processed-When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) "! <br /> I <br />� ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> r (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with an Joaguin County 9rdinance NI-.862 and the rules and regulations of the San Joaquin�Lo al Health District. <br /> Exact Site Address 0 CY / City/Town / l A. <br /> Owner's Nam �J r2 (C r Phone <br /> Address l o 1rl. City Vt. <br /> Contractor's Name (ful P i- License# Business Phone <br /> Contractor's Address {7G S' Kf r'l-a — Emergency Phon <br /> Is Certificate of Workman's Compensation:Insur on File With SJLHD? Yes No <br /> I TYPE OF WORK (CHECK): NEW WELL'Ll DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> I DISTANCE TO NEAREST: Septic Tank161 e7 Sewer Lines l/ .�_ Pit Privy <br /> r <br /> Sewage Disposal Field 10,0 Cesspool/Seepage Pit -= Other <br /> Property Line Id Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL t �� <br /> ❑, <br /> INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> L- <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing r <br /> ❑ IRRIGATION 8 GG VEL PACK Depth of Grout Seal O f <br /> ❑ CATHODIC PROTECTION I� ROTARY Type of Grout _Di <br /> ❑ DISPOSAL ❑ OTHER Other Information VC, 4, C/— <br /> GEOPHYSICAL Surface Seal Installed By: Owi tom <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump }{.p. <br /> PUMP REPLACEMENT: ❑ State Work Done w <br /> PUMP REPAIR: ❑ State Work Done Q <br /> DESTRUCTION'OF WELL: Well Diameter Approximate Depth 9 <br /> Describe Material and Procedure <br /> r• <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County A <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 /> I <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performanceof the work for which this 1 <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." I <br /> 1 will for a G out Insp tion prior to grouting and a final inspection. <br /> Signed X Title: _ Date: / I <br /> raw'Plot Plan on Reverse Side) <br /> F PARTMENT USE ONLY I <br /> PHASE I <br /> Application Accepted By -:..Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final InsPectiQn0-,;xCt <br /> Inspection By Date Inspection By ate <br /> Fee Is Du ea.r16: <br /> ❑ ANNUALLY ❑ PER ON ❑ PER SITE ❑ EACH ❑ January 1 &Received B Januar 31 <br /> - ry Y Y �❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> F <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED- <br /> AMOUNT <br /> FEE c�3 �� f <br /> t <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER' <br /> nn ! <br /> V <br /> Received by Dat - Receipt No. Permit No. - �r.. <br /> 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 />