Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. reTo ign The AppliconL� <br /> _F R FFICE USE: _ APPLICATION JUIN 18 1980 <br /> (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMITPUMP&WELL <br /> , <br /> SAN C,PQ 'N1 I ;O AL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY -{tAL�(� I�(rj Rim T <br /> Application is hereby madd t th& oaquinLocal Health District for apermit toconstruct and/or install the work herein described.This application is <br /> made in com liance witl'S��Jota�if�Count Ordi nce No. 1862 n the rules d regulations of the San Joa ocal Health District. <br /> Exact Site Address q City/Town " � <br /> Owner's Name Phone 2� q <br /> Address 3 ' City <br /> Contractor's Name f` Vic! l'r`C. License# G+ Business Phone---45�� <br /> Contractor's Address - Emergency Phone A <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 s Surface Seal Installed By: v <br /> PUMP INSTALLATION: Contractor 0'19f AO G - ° /- r <br /> Type of Pump 9 H.P. <br /> PUMP REPLACEMENT: ,}�Staff Work Done e�c �estI� <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. r` <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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will all f a Gr, t nspection prior to grouting and a final inspecti_gn. � <br /> Signed X Title: ��`�--Q�"-� Date: e-_ 1Z� <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By — Date <br /> Additional Comments: <br /> Phle 11 Grout Inspection Phase III Final Inspection <br /> Inspection By. Date Inspection By Lyl Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> }� f ( / AMOUNT <br /> FEE `tYI E � <br /> LESS <br /> PRORATION <br /> LPENALTY <br /> D to Receipt No. Permit No. Issuance Date Mailed Delivered <br /> T—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />