Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Com IU4.i�Wr�o,6 A/Th Pt Ion. <br /> FOR OFFICE USE: APPLICATIO <br /> (For Non-Transferable, Revocable,Suspend 0 1980 <br /> s L ENVIRONMENTAL HEALTH PERMIT FgeARN <br /> SA <br /> (COMPLETE IN TRIPLICATE) WATER QUALITYWCAL <br /> r Ins�IF tla*� <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct an o (tYftrdv�r�cf i&Tn described.This application is <br /> made in compliance with Count dinanc No. 1862 and th�rul�s r ulations of the San in Local Heath Dtrict <br /> Exact Site Address �/ 4W 7c'% G� City/Town J�/�ijl� CEJ <br /> Owner's Nam o ( ' Phone B` <br /> Address I ' City NLS W;op <br /> ' <br /> Contractor's Name CI ,� License# Busin�Iona � • <br /> Contractor's Address y Emergency Phone GGLL <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes I-- 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 �n <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL urf a Seal Ins led By: th\\ <br /> PUMP INSTALLATION: 1✓ Contractor Az <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 <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 hir'N or sub-contracting signature certifies the following:"I certif that in the performance of the work forwhich this <br /> permit i iss shall employ s subject to workman's compensati aws of California." <br /> I II c I r nspectio prior to grouting and a final inspectio , / t'J -- <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEP RTMENT USE ONLY <br /> PHASEIZZ <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase 111 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 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEESdb <br /> LESS G� J <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER 04 <br /> OTHER <br /> ved by Date Receipt No. Permit N Issuance Date Mailed Delivered <br /> L COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />