Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: p APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL t <br /> 114 yn,Z ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) ��:/r /,/, +'YWaTER QUALITY <br /> Application isherebymadetot SanJoaquinLocal fleal.th District for apermittoconstruct and/or install the work herein described.Thisapplicationis <br /> made in compliance with Sanrr Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address. City/Town &J 16;1> f <br /> Owner's Name Phone S <br /> Address CityF.Ivone �7 <br /> Contractor's NftmelLicense#la-3 3 Business Ph6 JC I <br /> Contractor's Address -� Emergency Phone <br /> Is Certificate of Workman's Compensation Ins6rance on File With SJLHD? Yes No G1 <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> b <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: El Work Done , <br /> PUMP REPAIR: [� State Work Done <br /> DESTRUCTION OF WELL- Well Diameter V Ar Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San"County # <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. s <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> 'w 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(tiring 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." <br /> I w I call for a Grout Inspection prior to grouting and a final inspection. <br /> 4�a4441!_ Q t- — Date:Signed X ,�_, nll .�� �moo,hCge:.�(Draw Plot Plan on Reverse Side) <br /> FOR EPART ENT USE ONLY <br /> PHASE I © r <br /> i Application Accepted By Date <br /> Additional Comments: i <br /> Phase II Grout Inspection /' /P se Final pection ' <br /> Inspection By Date /V/iT Inspection By!/l� ate <br /> i Fee IS Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received Ry July 31 <br /> REMIT <br />` BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE s. Y' <br /> LESS <br /> PRORATION <br /> PLUS ~ <br /> PENALTY <br /> OTHER <br /> COTHER <br /> Received by Date Receipt No. Permit No. I Iss ante Date Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,-CA 95201 <br />