Laserfiche WebLink
Applications Will Be Processed Whe%Submitted Properlycompimea. tie sure ioSign ine %ppisuailvll <br /> FOR OFFICE USE: <br /> APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WALL � <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLIy`:.TE) WATER QUALITY <br /> Application is hereby mau.:to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is 6 <br /> made in compliance with ;a J quip County Ordinan a No. 1162 and a les and regulations of the San Jo n Local Health District. <br /> City/Town <br /> Exact Site Address y e <br /> Owner's Name . Phone <br /> Address City `� <br /> Contractor's Name f' ri7 z icense# Q Business Phone____'-.s�7k <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <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 Other <br /> Property Line_ Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: `n <br /> PUMP INSTALLATION: Contractor \ <br /> Type of Pump H.P. V <br /> PUMP REPLACEMENT: V State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 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 <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 will call for a out I Spec tion prior to grouting and a final inspection. ,t <br /> Signed X Title: Iecd Date: 1 � <br /> (Draw Plot Plan on Reverse Side) <br /> OR PARTME T USE ONLY <br /> PHASE I �Q <br /> Application Accepted By Q Date / <br /> Additional Comments: <br /> Phase II Grout InspectionP a II Fina <br /> Inspection By Date Inspection B aA? A-1- <br /> & <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ Janu 1 Received By January 31 July 1 &Received By Jufy 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT OUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE Jor <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 1-wN—i , 7 <br /> C 3L Ott <br /> Received by are Receipt No Permit No. Issuance Date Mailed Delivered <br /> APPLI-CAN <br /> ALL COPIES T _ENVIRONMENTAL HEALTH PERMITISERYICES 1601 E.HAZELTON AVE.,P.O.Box 2009. STOCKTON,CA 95201-- <br />