Laserfiche WebLink
Applications Will Be Processed When Submitted ProperlyCompletea. tse*ure ,v a1w., I— <br /> i <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transterable,-Revocable;Suspendable) f PUMP&WELL 4 <br /> ENVIRONMENTAL HEALTH PERMIT // l <br /> II <br /> WATER QUALITY . �� ..,,,, <br /> (COMPLETE IN TRIPLICATE) <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 <br /> made in compliance with San Joaquin County 0 ina No. 1862 d the 1e nd regulations of the 5a aqui Health District. it <br /> City/Town �., <br /> Exact Site Address 4 ^_ so <br /> Phone.. ,I <br /> Owner's Name City I_ <br /> Address <br /> Contractor's Name License# 7 14 Business;one <br /> - Emergency Phon dz� <br /> Contractor's Address No 6"' <br /> Is Certificate of Workman's Compensation nsurance on File With SJLHD? Yes No <br /> - <br /> TYPE OF WORK {CHECK): NEW WELL DEEPEN ❑ RECONDITiON <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> Septic Tank Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: <br /> Cesspool/Seepage Pit Other <br /> k Sewage Disposal Field i <br /> Property Line Private Domestic Well' Public Domestic Well I� <br /> INTENDED USE TYPE OF WELL I <br /> ❑ INDUSTRIAL <br /> 11 CABLE TOOL Dia. of Well Excavation <br /> ❑ ED Dia. of Well Casing 11 <br /> I' DOMESTIC/PRIVATE DRILLGauge Gof Casing <br /> ❑ DOMESTIC/PUBLIC C1 DRIVEN <br /> 11 GRAVELPACK Depth of Grout Seal <br /> ❑ IRRIGATION <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout II <br /> ❑ DISPOSAL ❑ OTHER Other information <br /> Surface Seal Installed By: <br /> ❑ GEOPHYSICAL !i w <br /> PUMP INSTALLATION:' Contractor !� <br /> H.P. II <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 10 State Work Done' I <br /> DESTRUCTION OF WELL: <br /> Well Diameter ��A�ppate Depth II <br /> Describe Material and Procedure II <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 HealthDistrict. <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, 1 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." J <br /> I I will call for a Grout Inspection prior to grouting and a final inspect n. I. > + - „ <br /> Title: Date: d' <br /> Signed X - <br /> (Draw Plot Plan on Reverse Side) <br /> s <br /> FOR DEPARTMENT USE ONLY T I <br /> PHASE 1 Date <br /> Application Accepted By I <br /> Additional Comments: <br /> ". Phase III Final Inspection <br /> Phase 11 Grout Inspection i <br /> Date . Inspection By. j t Date } <br /> Inspection By - ii. <br /> PER UNIT ❑ PER SITE - ❑ EACH ❑ January 1 &Received By nuary 31 ❑ July 1 &ReceivedByJuly 31 ll <br /> Fee Is Due: ❑ ANNUALLY'"'°.' ❑ `II <br /> ;BILLING. REMITTANCE .. $ -.L-- - LINT DUE CHECKED !p <br /> BASE' EXPLANATION DATE DATE REMIT D' AMOUNT <br /> FEE <br /> LESS fl <br /> PRORATION Il <br /> PLUS <br /> PENALTY R <br /> OTHER !� <br /> OTHER ,- - - <br /> Receipt No Permit No...- ._3 r �� Is ance te. Mailed _ Delivered- <br /> Received by Date - l <br /> 1601 E.HAZELTON AVE.,P.O.90:2009 STOCKTON,GA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES _ jl <br />