Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OF <br /> -c USE: APPLICATION 4 <br /> ^' (Far Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> ~(COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaq in cal ea ism tforapermittoconstructand/or install the work,herein described.This application is <br /> made in corlipliance ith San J n 2 nd the rules and regulations of the San Joa Local Health District. <br /> Exact ite Address p �� � City/Town o C_C:tn°AJ = Com-* <br /> tName L�c N �L Phone _ �7 o2C7 <br /> Owner's Name <br /> Address ad � �GGf City <br /> ' <br /> Contractor's Nam of Llcense,9V Business Phone <br /> Contractor's Address ergency Phone yq <br /> Is Certificate of Workman's Compensation Insurance on File With SJL ? Yes t--- No <br /> TYPE OF WORK (CHECK): NEW WELL 21'DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR© <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Priv <br /> Sewage Disposal Field Cesspool/Seepage Pit Other ---- <br /> Property Line 6�3l Private Domestic Well ' Public Domestic Well <br /> INTENDED USE TYPE OF WELL �/ �/ f <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing // 1 <br /> ❑ IRRIGATION ❑ F�GRA�VEL PACK Depth of Grout Seal D <br /> 110 CATHODIC PROTECTION _C l ARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: f <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth ► <br /> Describe Material and Procedure y <br /> 1 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. <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich 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-contra ' signature certifies the following:"I certify that in the performance of the work for which this <br /> ermit is issued, I shall em Io rson ubject to workman's compensation laws of California." <br /> I call for a Grout sp ti or to g outing and a final inspection: V <br /> Signed X t Title: Date: <br /> aw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> ft <br /> Application Accepted By Date <br /> Additional Comments: <br /> s ro f In pection $� Pha II al Inspectlon <br /> Inspection BAC Dave _ �__ / <br /> Y PER UNIT ❑4,twnH ';6 y'anu 1 &Received R Ja 1 ❑ Ju! 1 & eceived B I Fee Is Due: ❑ ANNUALL ❑ Y Y Y Y <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT i <br /> FEE <br /> LESS <br /> PRORATION _ <br /> s <br /> PLUS <br /> 1 PENALTY <br /> OTHER <br /> OTHER ' <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO; ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZII AVE.,P.O:Bo=2009 STOCKTON,CA 95201 ._ <br />