Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Comp! B u I1 a ipli t l .10 <br /> FOR OFFICE USE: APPLICATION rilf <br /> (For Non-Transferable, Revocable,`SuspendablAU G 2 1HAAP&WELL <br /> Ay ENVIRONMENTAL HEALTH PERMIT = <br /> SAN JOAQUIN LOCAL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY , HEAI� �4 .® --DICT:,; <br /> Application is hereby made to the San Joaquin Local Health District for a permit toconstructand/ormsta t ework. ereindescribed.Thisapplication is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations-of the San oaquin Local Health District. <br /> Exact Site Address — x - City/Town <br /> �✓ <br /> Owner's Name r `" <br /> Phone <br /> Address '�•,... � City <br /> Contractor's Name , lJ'a" � "t `L• a'rLicense## /�Q Busin s Phone". Q� / _7:j <br /> Contractor's Addressr.� '1./ �e .,�. ,f: ' i=Emergency Phone 1� <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL'❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ C>b <br /> WELL CHLORINATION ❑ . WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR. <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit' <br /> Other. <br /> r- Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well'Excavation <br /> lip <br /> 'DOMESTIC/PRIVATE t"E] DRILLED Dia. of Well Casing ' <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing T <br /> ❑ IRRIGATION ❑ GRAVEL PACK- Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY a Type of Grout i <br /> ❑ DISPOSAL, ❑ OTHER �� Other Information < <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <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 - x '� Approximate Depth <br /> Describe Material and Procedure (�j+ <br /> t �S <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County' <br /> t,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 for which this permit f <br /> is issued, I shall not employ any person in such manner asAo 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 forwhich this <br /> permit is issued, 111 employ persons subject to workman's compensation laws of California." <br /> I WV'Cll for,0 Gr on prior to grouting and a final inspectio• . > <br /> Signed X -- Title: <br /> Datef . <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY ]I <br /> PHASE I t <br /> 'Application Accepted By Date 4 <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final Inspection <br /> Inspection By Date - Inspection Date ter <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January i &Received By January 31 ❑ July 1 &Received By July 31 <br /> - 3 -'BILLING - REMITTANCE REMIT ` <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE 5 45 [I F <br /> LESS tti/ <br /> PRORATION <br /> PLUS • .. .... - ,. .�. - <br /> PENALTY - - <br /> OTHER i <br /> OTHER } <br /> zn <br /> Received by Date Receipt No. Permit No Issuance 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 />