Laserfiche WebLink
' Applicatioris Will Be Processed When Submitted ProperlyCompleted BeSureToSignTneApPlicallon. <br /> R-OFFICE USE: � ' R-PPMATION <br /> (For Non-Transferable, Revocable, Suspendable) ; P[1MP&WELL <br /> , . <br /> ENVIRONMENTAL HEALTH PERMIT * <br /> 'eWATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby'made to the San Joaquin Local Health District for a permit to construct an <br /> install the work herein described.This application is <br /> made in compliance with San J q in County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address C- rjp- City/Town.4 1er /. <br /> Owner's Name ti ►5 !7? Phone 3/— ��+� J <br /> r Address � ,�� r City �.�� <br /> r' Business Phone <br /> `Contractor's Name .S4 'J License# <br /> Contractor's Address Emergency Phone i <br /> I Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> CTION <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION 0 DESTRU <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR© <br /> REPLACEMENT D f <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines d4 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 <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC I ❑ DRIVEN Gauge of Casing 1 <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal u <br /> 1:1 CATHODIC PROTECTION ❑ ROTARY Type of Grout �CN <br /> El DISPOSAL F-1OTHEROther Information i7i< Gw <br /> ❑ GEOPHYSICALi �1i✓ <br /> Surface Seal Installed By: <br /> I PUMP INSTALLATION: Contractor dF <br /> O / <br /> Type of Pump H.P. C��✓ <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 forwhich 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 Inspection o grouting and a final inspection. <br /> Signed X I - Title: ill Date: G�27—,if <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY I <br /> PHASE 1 �1 Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout Inspection Phase Ill Final Inspection 33 <br /> Inspection By Date - Inspection By - Date <br /> I <br /> Fee IS Due: ❑ ANNUALLY- El PER UNIT EI PER SITE EACH ❑ January t &Received By January 31 El July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE - CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> 43 <br /> LESS <br /> PRORATION <br /> PLUS Vh I"1�hWA� 1Y��1 v�711n Aiu {tea J vi6 t'f Ir111 ✓H�v�'! rlf7 <br /> PENALTY <br /> OTHER L <br /> OTHER a9�`I'u 0. t�)7 r4f1 (ii^T <br /> e � <br /> yo <br /> r. <br /> Received by ate Receipt No. Permit No. — Issuance tate Mailed Delivered <br /> APPLICANT ALL COPIES TO: ,ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOGKTON,CA 95201 <br /> 'may _ _. �' C� <br />