Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
s Applications Will Be Processed When Submitfed`PFoperly Completed:"Be Sure To Sign The Application. <br /> f FOR OFFICE USE: <br /> APPLICATION r" <br /> ' (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> �C (COMPLETE IN TRIPLICATE) WATER QUALITY, <br /> f Application is hereby made totheSan Joaquin Local Health District fora permit to construct and/or install the work,herein described.This application is <br /> I made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> r Exact Site Address City/Town <br /> Owner's Name J3,z, Ci` Phone <br /> Address r City <br /> f <br /> Contractor's Name icense# �� Busihess Phoney=Z7�'r� 6" <br /> ' <br /> � <br /> Contractors Address /,��:Z. -- Emergency Phone � � r <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITICY013 DESTRUCTION❑ <br /> i WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP-I`NSTALLATIONA _PUMP.REPAIR C1 <br /> REPLACEMENT* � <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> _ n <br /> M Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL. <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of,Well Excavation <br /> 11DOMESTIC/PRIVATE El DRILLED Y Dlwof'Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing _ <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 114 <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout °h <br /> Cif <br /> 3 ❑ DISPOSAL ❑ OTHER Other Information (JI <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump P. <br /> PUMP REPLACEMENT: JO State Work Done <br /> C PUMP REPAIR: ❑ State Work Done i <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth -L <br /> Describe Material and Procedure <br /> u ' ¢ <br /> I hereby certify that I have prepared this application and'that the work will be done in accordance with Sari 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." <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 /> I vAl call for a Grout Inspection prior to grouting and a final'inspection. - <br /> Signed X Title: ... G� Date: f -� _ <br /> (Draw Plot Plan 's- <br /> on Reverse ide) <br /> Y <br /> 1. FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By - {-- -- Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Pt C. Final Inspection <br /> Inspection By Date Inspection By A bate <br /> Fee 15 Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> 1 BILLING REMITTANCE $ - REMIT <br /> BASE - EXPLANATION DATE DATE REMITTED 44 AMOUNT OUE CHECKED <br /> AMOUNT <br /> 0 LP <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS .. . <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 064 <br /> G(011 <br /> Receivedby Date - _ Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES-TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952 '7 <br /> 1 F,_y,_- <br />