Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR.OFIF CE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) z <br /> /PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) ,gitrnerldq-CI) / WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made iri compliance with San Joaquin County Or,finance No. 1$62 and the rul and re ulati ns of the Sa/n� Joaquin Local Health District. <br /> Exact Site Address 7 + +° ity/Town <br /> Owner's Name b9A Phone <br /> Address O� City <br /> Contractor's Name LS ,tC�YGS License# Business Phone `��� <br /> Contractor's Address t` �r f�! Emergency Phone <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© <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank �®0/ Sewer Lines Pit Privy <br /> Sewage Disposal Field X00` Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL J+ <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> f 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 /> r PUMP REPAIR: ❑ State Work Done oO <br /> r DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> f ' <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 r � <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. V , <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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I wit call tar a Grout sp on prior to grouting and a final lnspection. <br /> Signed X Title: .. (fes Date: 8 <br /> ( aw Plot <br /> an on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI f <br /> Application Accepted By Date I <br /> Additional Comments. ;Ma�� <br /> /Phh� rout Inspection ` / Phase III Final 1 pection <br /> Inspection By °� Date/l"i �� Inspection By ��'� Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> t REMIT <br /> k BASE EXPLANATION BILLING REMITTANCE' - $ AMOUNT'DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE L <br /> ` LESS <br /> PRORATION , <br /> PLUS <br /> PENALTY <br /> OTHER <br /> I <br /> OTHER <br /> L Received by Date Receipt No. Permit No I suance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.;P.O.Box 2009. STOCKTON,CA 95201 <br /> a� _a <br />