Laserfiche WebLink
Application B rocessedgWr}hOtitted Property Completed. Be Sure ToSignTheApplication. <br /> FORT rFICEItSE: C�C� t� ` 11 A,.P�P KATION <br /> UU For Non-Tr nater �e, Revocable, Suspendable) <br /> — - ,; ' PUMP&WELL <br /> �Ei`il (I� TAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) SEWATER QUALITY ��� g_ /�-o _03 <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 w,,iit�ttgh San Joaquin Count Ordinance No. 1 62 an the rule nd re ul s of the San Joaquin Health District. � <br /> Exact Site Address P Y4 City/Town es Y' <br /> g w ( 11 C>13 <br /> Owner's Name . I ` /� ' �- Phone I <br /> Address3 City <br /> Contractor's Name ` d" 5 � License # _.� �� Business Phone � <br /> Contractor's Addk . %6 164— Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELD DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 91--r-�PUMP REPAIR❑ <br /> REPLACEMENT❑ i <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy { <br /> Sewage disposal Field Cesspool/Seepage Pit F" Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ,❑,� INDUSTRIAL 3—MBLE TOOL Dia. of Well Excavation s� <br /> I�-DUMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing / <br /> C3DOMESTIC/PUBLIC ❑DRIVEN Gauge of Casing <br /> %-MRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout c� <br /> ❑ DISPOSAL -0-OTHER Other Information <br /> ❑ GEOPHYSICALI Surface Seal Installed By: <br /> f, <br /> PUMP INSTALLATION: .. Contractor <br /> Type of Pump `" -urn H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OFIWELL: Well Diameter f ` 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 Joaquin County f'T� <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. �� <br /> Homeowner or licensed agent's signature certifies the fallowing:°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 /> peYmit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 'I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X Title: +- ._ <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI,� <br /> E <br /> Date <br /> ` <br /> Application Accepted By ' <br /> Additior5al Comments- <br /> Pb4s 1 Grout In ection rP ie'lll Fin Inspection <br /> Inspection By ate � v _ Inspection Byf/t"C Dame <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNI ❑ PER SITE ❑ <br /> EACH ❑ January 1 &Received By January 31 El 1 Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE s AMOUNT DUE CHECKED <br /> f BASE EXPLANATION DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS ' <br /> PRORATION _ <br /> PLUS ` <br /> PENALTY <br /> OTHER <br /> j <br /> OTHEEyR} k <br /> tr� I ola� �� ��3 3� o'S� <br /> Received by ��G Receipt No. Permit No. Issuance Date Mailetl Delivered <br /> ' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 �_ STOCKTON,CA 95201 <br />