Laserfiche WebLink
ApplicationsWill BeProcessedWhen Submitted ProperlyCompleteduseTo Sign The Applicati <br /> FOR OFFICE USE: APPLICATION LM <br /> �''o M <br /> (For Non-Transferable, Revocable,Suspendable) APR 9 19$0 <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERM§AN JOAOUIN LOCAL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY HEALTH DISTRICT <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 compliance with San Jooa^quin County Ordinance No. 1882 and th ruu s and regulations of the San JoaquinLocalHealth District, <br /> Exact Site Address ` l I 4: S• V/Q 1t� AkL4711� ��' City/Town Z&e- p�o'`� �1 <br /> Owner's Name T ►1 !V �� TxIJ,�?t Phone e �140 <br /> Address ^ City— <br /> Contractor's Name .v License#-12 D Bu Hess Phone��7a � O <br /> Contractor's Address 2vn�3 Emergency Phone CZ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes, 0 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 vvv��l <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: C <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: M State Work Done L _SSRAC 361_ <br /> PUMP REPAIR: ❑ State Work Done A <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 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 Wftf all f r a Gro s tion prior to grouting and a final inspection <br /> Signed X Title: Dater'–`� <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By ""^'� �✓ Date 0 <br /> Additional Comments: <br /> Phase 11 Grout Inspection P11 e III Final Inspection <br /> Inspection By Date Inspection By "' Date ` "f <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 DATE DATE REMITTED AMOUNT DUE CHECKED <br /> `C AMOUNT <br /> FEE �J <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received 6y Date Receipt No Permit No issuance Date Mailed Delivered <br /> .� APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95'20Q� <br />