Laserfiche WebLink
Applications Will Be Processed When Submitted Properly o <br /> ".S�FOR"OFFIGE USE: <br /> .. APPLICATION <br /> r _ (For Non-Transierable, Revocable, Suspendable) PUMP&WELL <br /> ;k ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN 2-IN `t`Z A °�s �ATEA QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and <br /> install the work herein described.This application is <br /> made in compliance wit San J aquin�r�ce�4. �No.18@2 and the rules and regulations of the San oaq i Local Health District. <br /> Ii �.,,,,,9 City/Town <br /> Exact Site Address <br /> OD(- Ili-0/ phone <br /> Owner's Name <br /> I m 0- 6 City <br /> Address tol License <br /> �,y <br /> 3 ?3 Business Phone_�� <br /> Contractor's Name 4, 11 lilt <br /> kr.� Emergency Phone Z'r <br /> Contractor's Address 2 +�? r�• ' <br /> Is�Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> Na r <br /> TYPE OF WORK {CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> 4' <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 11 PUMP INSTALLATION �f PUMP REPAIR❑ 9 <br /> rl <br /> REPLACEMENT❑ r r _ <br /> DISTANCE TO NEAREST: Septic Tank d Sewer Lines Pit Privy t <br /> Ce <br /> Property <br /> Pit Other <br /> iSewage Disposal Field <br /> Property Line Private Domestic Well Public Domestic Well <br /> fr <br /> If INTENDED USE TYPE OF WELL <br /> E 0 INDUSTRIAL 11 CABLE TOOL Dia. of Well Excavation rr c N <br /> R-DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> 11 DRIVEN Gauge of Casing <br />� ❑�, DOMESTIC/PIJBL.IG �a <br /> i D IRRIGATION ,_ ❑ GRAVEL PACK Depth of Grout Seal N <br /> 0 CATHODIC PROTECTIONf� Iii-ROTARY + .,z.� �:A. T Type of Grout <br /> - Other Intormatlon <br /> ID DISPOSAL ❑ OTHER <br />` El GEOPHYSICAL Surface Seal Installed By: i <br /> PUMP INSTALLATION: Contractor <br /> ` Type of Pump H P' rj <br /> „PUMP REPLACEMENT: 13-State Work Done f <br /> PUMP REPAIR: ❑ State Work Done \ '� <br /> DESTRUCTION OF WELL: <br /> -Wei Diameter Approximate Depth <br /> iI Describe Material and Procedure <br /> ! � <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. y I <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 or sub-contracting signature'certiiies 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 compgnsation laws of-California." } <br /> I I I call r a Grout Inspe ion prior to grouii and a final ins ection. <br /> Title: Date: <br /> .rgigned X _. <br /> raw Plot Plan on Rever a Side) <br /> SE ONLY <br /> 9f <br /> ' of F R DEPAR MENT•U <br /> I� PHASE I ! s` v ' Date /� C7 <br /> I Application Accepted By <br /> I Additional Comments: <br /> Phase H Grout Inspection Phase Final nspection <br /> -fie- ?g Inspection By Date- <br /> Inspection By DateBy <br /> - <br /> Ij Fee IS Due: ElANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMITuIy 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> - BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> we <br /> FEE W+ <br /> LESS <br /> PRORATION <br /> PLUS <br /> II PENALTY <br /> R OTHER <br /> OTHER <br /> •fin <br /> -79 <br /> Received tly <br /> Date J Receipt No. Permit No. -issuance Date Mailed Delivered <br /> 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCICTON,CA 95201 <br /> + i <br /> APPLICANT—RETURN-ALL COPIES TO ENVIRONMENTAL HEALTH PERMITISERYICES - <br />