Laserfiche WebLink
:.� Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSign TheApplication. <br /> FOR OFFICE USE: APPLICATION <br /> _ (For Non-Transferable, Revocable, Suspendable) <br /> 1 <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT } <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules nand egulations of the San Jo�aqu_in o al Health District. <br /> Exact Site Address��P� '0M, W� City/Town �r _(Qs � <br /> Owner's Name Phone ,,�� � <br /> Address �� w City—,4;*. <br /> Contractor's Name License# Business Phone 7�/�-Z <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes &-mmw� No <br /> TYPE OF.WORK (CHECK): NEW WELL ER'0'DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ ..� <br /> a WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> [ DISTANCE TO NEAREST: Septic Tank /.Zp Sewer Lines�6go Pit Privy <br /> [ Sewage Disposal Field Cesspool/Seepage Pit Other <br /> f .Property Line Private Domestic Well .r��/ Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> HOMESTIC/PRIVATE 13DRILLED Dia. of Well Casing <br /> � <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing l�� - <br /> tt' ❑ IRRIGATION �� AVEL PACK Depth of Grout Seal <br /> t' ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> I ❑ DISPOSAL ❑ OTHER Other Information d <br /> [ <br /> El GEOPHYSICAL Surface Seal Installed By: <br /> r <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. r l <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 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 /> 41 <br /> I will call for a Grout Inspection pri r to grouting and a final inspection. <br /> Signed X Title: _A A. -000-0' Date: — <br /> + (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I if <br /> Date <br /> Application Accepted By -�' �o <br /> Additional Comments. - - <br /> ha 11 Gr t Inspection Phase III Final Inspection <br /> ` � Ins ection B <br /> Inspection By bate p Y Date <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By,luly 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> I 414.3 F ° <br /> FEE <br /> LES <br /> PRO - Y <br /> PRORATION <br /> PLUS . <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. m o. Issu nce ate Mailed Delivered <br /> "1BOi E.HA2ELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO:I ENVIRONMENTAL HEALTH PPERMIT/SERVICES <br />