Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in co�rlpliance with,San Joaquin unty Ordinance No 1862`and'the``rul' 'a`lid reguhatlons of the San Joaquin Local Health District. r <br /> Exact Site Address City,Town <br /> Owner's Nyme Phone ca27� k <br /> Address City�:7 ea <br /> Contractor's Name License# M . Business Phone <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 IM + Cesspool/Seepage Pit Other <br /> Property Lina Private Domestic Well Public Domestic Well <br /> INTENDED USE I TYPE OF WELL r� <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing - <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing E1Ale. - <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: <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 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 /> Homeowner 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 /> twill all for a Grout Inspec' prior to grouting nd afinal nspection. (� <br /> Signed X Title: Date: `f l <br /> (Draw PI Ian on Rever ide) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 12 <br /> Application Accepted By Date <br /> Additional Comments: �� <br /> T PhaGrout Inspection Phase 111 Final Inspection ✓ <br /> Inspection By Date j!`j ��" Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January\31 ❑ July I &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION A LINT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE o o !� Lv I'\.riLESS <br /> PRORATION � <br /> PLUS <br /> PENALTY <br /> ! C✓{i!![ vt/ �£ J+� <br /> OTHER <br /> JCP ~ o r <br /> OTHER �� C�- 4V�L. r p42% <br /> a <br /> J <br /> Received by Date Receipt No.. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95241 <br /> a <br />