Laserfiche WebLink
Applications Will Be Proce d When Submitted Properly Completed. Be Sure16Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> I U Z <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) <br /> �`j'I' r WATER QUALITY <br /> Application is herebymadetotheS JoaquinLocalHeaI istrictforapermittoconstructand/or install thework herein described.This application is <br /> made in compliance with San Joa i County Ordinance No.1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address E City/Town l <br /> Owner's Name S4a JO © u) Go`)N1 t Phone `IL t+ <br /> Address <br /> ZZ l.� - City S 0 4c-V_-I to .� <br /> 2 <br /> Contractor's Name NDN tai�,i BIZ eS License# ZRp C)1I Business Phone <br /> Contractor's Address S Z S fir_-L 0t 3 i)A LE MD� S'L o 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❑ DESTRUCTIONS <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: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> (oj�2 " Approximate Depth 50 <br /> DESTRUCTION OF WELL: Well Diameter ,-f.Q 20 � S _ t. w.T t� <br /> tS Describe Material and Procedure <br /> ��,s f��� �>✓t.1'TuN t)Sc�3 C. A 'T�&VitF- T0RE. <br /> h r by 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 /> will call for a Grout In tion prior to grouting and a final inspection.P (C <br /> Signed X <br /> <► 29 P� Title: -• �-` Date: <br /> (Draw Plot Plan on Reverse Side) <br /> /FORD PARTM1 USE ONLY <br /> d <br /> T J r- <br /> PHASE I �i 7 /`Y? 4/yt Date ` - <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout Inspection Phase Iii Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMIT 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE re. "- <br /> LESS <br /> PRORATION <br /> PLUS 2, 43 ` <br /> PENALTY ) n /- <br /> OTHER (, [Cv✓ ,V1 17 <br /> OTHER h U <br /> 4_7 ION <br /> Received by Dae Receipt No. Permit No. I suanc Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952D1 <br />