Laserfiche WebLink
,.Applications Will Be Processed When-Submitted Properly Completed. Be Sure To Sign The App�"Ic=5W <br /> FO "OFFICE USE:=" APPLICATION 1 <br /> (For Non-Transferable, Revocable,Suspendable) <br /> 1 f PUMP&WEN L <br /> ENVIRONMENTAL HEALTH PERMIT <br />[ (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> 1 Application is hereby madeto theSan Joaquin Local Health District fora permitto constructand/or install thework herein described,This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joa uin Local Health District. <br /> Exact Site Address 3 i _ City/Town <br /> Owner's Name Phone <br /> Address — �_ City <br /> Contractor's Name License#�!/ / ��Business Phone r f <br /> Contractor's Address Emergency Phane - <br /> Is Certificate of Workman's Compensati n Insurance on File With SJLHD? Yes X No 0 <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ N <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 1 <br /> REPLACEMENT❑ <br /> 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 <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 Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <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 /> Describe Material and Procedure <br /> 1 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 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." J <br /> Contractor's hiring orsub-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 /> E ` <br /> r I ill call for a Grout Inspection prior to grouting and a final inspect' <br /> Signed X _ _ Title: - Date: - <br /> t (Draw Plot Plan on R' erse Side) <br /> f FOR DEPARTMENT USE ONLY <br /> PHASE <br />' Application Accepted By —� � �sC� � Date <br /> j Additional Comments: - <br /> Phase II Grout Inspection Phip til Fina spectiorliff <br /> Inspection By Date Inspection By ate is 6 <br /> ` Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br />! LESS <br /> PRORAT4ON _ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No Permit No. Issuance DateMailed�P Delivered <br />�' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 95201 <br />