Laserfiche WebLink
FPlicallons Will Be Processed When Submitted Properly Completed. re-� n r --------- <br /> FOR " <br /> OFFICE USE: �_jZAPPLICA'F j11pPlication. <br /> (For Non-Transferable, Revof seenle) <br /> ENVIRONME�E H P�F�p�rTZ 1 19$Q PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY f�a1lU�lli� <br /> I Application is herebymadetotheSanJoaquinLocalHealthDistrictforapermittoconstruc n r' <br /> J <br /> made in compliance with San Joaquin C my pr Hance No1862 and h <br /> ' . e les andI� e � �ein described. This application is <br /> Exact Site Address a� IQ�wf� b6 <br /> �� Juin Local Health District. <br /> City/Town <br /> r Owner's Name <br /> Address Phone <br /> Contractor's Name City <br /> License# C­-373 7 3 Business Phone ij t <br /> Contractor's Address <br /> Emergency Phone � <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? <br /> TYPE OF WORK (CHECK); NEW WELL❑ DEEPEN El Yes �� No. C <br /> RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ElWELL ABANDONMENT 11OTHER ElPUMP INSTALLATION ❑ <br /> REPLACEMENT PUMP REPAIR®� <br /> ❑ <br /> 4 <br /> DISTANCE TO NEAREST; Septic Tank '�.�, Sewer Lines Pit Privy <br /> L Sewage Disposal Field Cesspool/Seepage Pit <br /> Property Line Private Domestic WellOther <br /> TYPE OF WELL <br /> INTENDED USE Public Domestic Well <br />_ <br /> ❑ INDUSTRIAL ❑ CABLE TOOL - <br /> ❑ DOMESTIC/PRIVATE ❑ Dia. of Well Excavation <br /> LIG <br /> ❑ DOMESTIC/PUB DRILLED Dia. of Well Casing <br /> ❑ DRIVEN --Gauge of Casing <br /> ❑ IRRIGATION <br /> ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY <br /> ❑ DISPOSALType of Grout ` <br /> ❑ OTHER �OtheMnformation j <br /> 13 GEOPHYSICAL (e=--, <br /> PUMP-INSTALLATION: �r~1 Surface Seal Installed By: 4 <br /> Contractor �1J ��. <br /> PUMP REPLACEMENT: pe of Pump JKAH P - <br /> State Work Done - <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 1 ��~ `J <br /> Approximate Depth <br /> Describe Material and Procedure <br /> A V <br /> I hereby certify that f have prepared-tilis 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. # <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 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 ' call f It a Grout Ins p tion prior to gro ng and a final inspection. <br /> Signed X <br /> - - ,Title:: <br /> (DraDate: <br /> w o lan ori Reverse lde) ` <br /> y <br /> PHASE I FOR PAR MENT US NLY I ' <br /> Application Accepted By / <br /> Additional Comments: Date <br /> Phase II Grout Inspection <br /> Inspection By Date Ph II Final I OpectiDateo G <br /> �7" Inspection B � �II p <br /> Fee Is Due: 11 ANNUALLY <br /> 11 PER UNIT '0-PER SITE ❑ EACH <br /> ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLA ATION BILLING REMITTANCE $ REMIT <br /> DATE d DATE REMITTED AMOUNT DUE CHECKED <br /> FEE ' AMOUNT <br /> i <br /> LESS <br /> PRORATION <br /> PLUS k <br /> PENALTY <br /> z <br /> OTHER <br /> } <br /> OTHER <br /> Received by Date Receipt No. S Z ` <br /> P - Permit o. Issuan a Date Mailed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIAONMENTAL HEALTH PERMIT)SERYICES 4 Delivered <br /> 1601 E.HAZELTON AVE.,P.O.Box 211 STOCKTON ce QcIn. <br />