Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed.Oel�bure To Sign The Applicat <br /> FOR OFFICE USE: APPLICATION i Hq. <br /> (For Non-Transferable, Revocable, Suspendable) JAN G P[J�&WELL <br /> ENVIRONMENTAL HEALTH PERMIT AN .;QAUlN LOCAL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> �q&UU l��.TF�iCT <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or ins I e In escribed.This application is <br /> made in compliance with San Jo quin County Ordinance No. 1862V!d}he rules and regulations of the San Joaquin Local_Health District. <br /> Exact Site Address �A A/ UE tv U` City/Town Z�� <br /> Owner's Name a-)11/tom 373 Al-A ` Phone -P-1 <br /> Address _ City <br /> Contractor's Name S License#21!9140/13 Business Phonej <br /> Contractor's Address r tP03 &2D 1 ry Emergency Phone c9,0", -e— <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes Al No � <br /> TYPE= OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENTIR <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 /> 91 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: X State Work Done ­y-LAA' -f e sc 4 '5 <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth (rl <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. G <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich 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 orsub-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 wi all for a Gr t Insp tion prior to grouting and a final inspect'g T <br /> Signed X Title: _- �{q 2t2/ti. Date: /.2-7- <br /> V (Draw <br /> ate: /.2- <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepte y Date <br /> Additional Commen <br /> Phase II Grout Inspection Dase III Final Inspection G <br /> Inspection By Date Inspection By _I� l a Z- <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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> +r DATE DATE REMITTED AMOUNT <br /> FEE 1�' S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> -17? / �, ?,,I. C/ <br /> Received by ate Receipt No. Permit No. issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITJSERVICES 1601 E.HAZELTON AVE.,P.O.130■2009 STOCKTON,CA 95201 <br />