Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: a x APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT _ <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY S -� <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 i <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. 01 <br /> Exact Site Addressc74 r1� City/Town +n <br /> Owner's Name ` GLL Phone <br /> Address o r- City G <br /> Contractor's Name .�o�'�,�/ j License Business Phone — <br /> Contractor's Address 018 �I/f J Emergency Phone (� d 6S <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR 13 j <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank &6 -On4-- Sewer Lines .� Pit Privy <br /> Sewage Disposal Field O/rte✓ Cesspool/Seepage Pit Other , <br /> Property Line.2AQC-Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> 11 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 0 �� <br /> 11 CATHODIC PROTECTION 13 ROTARY Type of Grout AZV- <br /> ❑ DISPOSAL ❑ OTHER Other Information ' <br /> ❑ GEOPHYSICAL ,�9 Surface Seal Installed By. �f,�B r <br /> PUMP INSTALLATION: Contractor 199 i.L r�r�. LJe , r-i !�!Al ! - <br /> Type of Pump H.P. <br /> r <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done _ <br /> DESTRUCTIOP 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. 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 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 /> I will call for a Grout Ins ection prior to-grouting and a final inspection. Y <br /> 6—r <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br />{ FOR DEPARTMENT USE ONLY <br /> PHASE I L� <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phas II Grout Inspection se II Final Inspec n <br /> t � <br /> Inspection By Date Inspection By Dae <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 4 &Received By July 31 <br /> 11 REMIT <br /> I; BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE �^ DATE REMITTED AMOUNT <br /> FEE Q 0 2-qo <br /> LESS 6 <br /> l PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER �,. W t <br /> ' OTHER <br /> --jm x I - <br /> Received by Date- Receipt No. Permit No. Issuance Date Mailed Delivered=' . <br /> -APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICE$. ' 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,_CA 95201 <br />