Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. BeSureToSignTheApplication. <br /> FOR OFFICE USE: APPLICATION <br /> —01 (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) A4-7r-o b-v f-WATER QUALITV C 0 3 ---00o <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 an Joaquin oun 9yrdinance No.1862 and he rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address ' / 1 10 �+ �' a 'r" City/Town <br /> Owner's Name Phone <br /> Address ' City _ <br /> Contractor's Name License#� Bus'ness Phone a� I <br /> Contractor's Address Emergency P one <br /> is Certificate of Workman's Compensation I ance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELLFy DEEPEN ❑ RECONDITION DESTRUCTION© <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT I <br /> DISTANCE TO EAREST: 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 /> c+ -, <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing - peD <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> S <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal f�a <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout C"tat4A 11 <br /> ❑ DISPOSAL OTHER Other Information <br /> ❑ GEOPHYSICAL <br /> Surface Seal Installed By: 14&-A, <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done f <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 hereby certify that l 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. Q <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit c� <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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I II for a Grout In tion rior to uting and a final inspection. <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted y Date -2-92 <br /> Additional Comment : <br /> hese II Grout inspection j a III Final Inspection <br /> Inspection Date MInspection y Date ��lZ �3 <br /> 2- <br /> Fee Is Due: ❑ NNUALLY ❑ 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 /> DATE DATE REMITTED AMOUNT <br /> o� <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> IS bl � v <br /> Received by Date Receipt No. Permit No. Isp0ancelDate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOGKTON,CA 85201 <br />