Laserfiche WebLink
Applications WIII Be Processed When Submitted roper <br /> FOR OF�ICE.USAPPLICATION <br /> ` (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby madeto 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 with an Joaquin Cou ty Ordinance No. 1862 and the rules and regulations of the San Joaquin Local District.. <br /> a CZ City/Town <br /> Exact Site Address <br /> Phone ` <br /> Owner's NameCity � <br /> Address �' <br /> „-, S License#�LC� Bus , ess Phone <br /> Contractor's Name < Emergency Phone <br /> Contractor's Address .� � No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes �a <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION C3 DE <br /> STRUCTION❑ �� <br /> i WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER �P ���rt Of� ❑� <br /> REPLACEMENT �LT'lipPUM (1 e4'� --� <br /> Ia� Lies r Pit PrivySewer ny — - <br /> [, DISTANCE TO NEAREST: Septic-Tank Cesspool/Seepage Pit Other <br /> Sewage Disposal Field = - <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL pia. of Well Excavation <br /> 13 DRILLED Dia. of Well Casing <br /> DOMESTIC/PRIVATE ❑ DRIVEN Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC <br /> i ❑ GRAVEL PACK Depth of Grout Seal <br /> 1:1 IRRIGATION <br /> t ❑ CATHODIC PROTECTION 11ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 11 GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ® State Work Done P "" <br /> PUMP REPAIR: ❑ State Work Done <br /> �- � "�^ Well Diameter - —Approximate Depth <br /> DESTRUCTION OF WELL: i <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 <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 performanceof 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 /> fallowing:"I certify that in the performance of the work for which this <br /> Contractor's hiring or sub-contracting signature certifies the <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> l will c r a Grout Inspe n.p ' r,to grouting and a final inspection , <br /> Title: <br /> Signed X (Draw Plot Plan on Reverse Side) <br /> n FOR DEPARTMENT USE ONLY <br /> PHASE I Ill,le. Date1s-==—� <br /> Application Accepted By WWW�ww��w <br /> Additional Comments: se 11 Final Inspection A-1 <br /> Phase 11 Grout Inspection I. Date <br /> Inspection By <br /> Date Inspection <br /> ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 eived By January 31 ❑ July 1 &ReceiveRdEB�yI July 31 <br /> Fee IS DUB: ❑ ANNUALLY <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE RFWTTED AMOUNT <br /> EEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> t - <br /> OTHER <br /> Issuance Date Mailed Delivered <br /> D e Receipt No. Permit No-'- - <br /> Received by 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES - <br />