Laserfiche WebLink
' tion n Be Processed ubmitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: 18 1 8 19EQ APPLICATION <br /> " (For Non-Transferable,Revocable,'Suspendable) PUMP&WELL <br /> �I SAN "QUIN ONMENTAL HEALTH PERMIT <br /> HEALTH DIRY <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY 4 t <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 Joaqul ount Ordin nce No. 1862 and the rules and regulations of the San Joaquin L cal Health District. <br /> r d <br /> Exact Site Address ��®( - City/Town - . <br /> Owner's Name r " Phone " 2 <br /> b ' City <br /> Address <br /> ' <br /> Contractor's Name " License# Business Phone <br /> Contractor's Address '"° E 't 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❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRS <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 1-1DRIVEN Gauge of Casing <br /> f <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL t � Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> e_ <br /> / Type of Pump H.P. <br /> _ �=--u" �� s <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: ❑ State Work Done r <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 Sari 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 orsub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this ; <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call fora <br /> Grout Inspection prior to grouting and a final inspection. f <br /> Signed X � , Title: [ . '}^�J�f _ Date:.. <br /> (Draw Plot Plan On Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE IT `oL_0 <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection 7ByJanuary <br /> inal In ction . <br /> Inspection By Date Inspection ByDa I <br /> :f <br /> Fee Is Due: ❑.,ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Rec1 ❑ J iy I eceivedBy July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUN DUE CHECKED <br /> DATE DATE REMITTED AMOUNT . <br /> FEE .6 LA <br /> LESS _ r- <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER- _ C.. <br /> OTHER <br /> LL <br /> Received by Dat4 Receipt No - Permit ` f�IssGance Date. Maned Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> i <br />