Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> /a QUALITY ., <br /> (COMPLETE IN TRIPLICATE) a('�. � •'; �� i,C � �i y..., t •.:I•', :f,'[f I:� �' t"14. t a(� �3 - �SO ^Y i <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work-herein described.This application is <br /> made in compliance with San Jo uin County Ordinance No. 1.862 and the.rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Addresses, cj�-( �*` P A• � ' -City/Town _ t <br /> Owner's NameS -��iLcc� .r ir-. izc*v� T Phone / /C—�sey <br /> Address ,�D [A ` r ... 4 2® : " City.r. L <br /> . <br /> Contractor's Name ' �` License Business Phone <br /> Contractor's Address �� rr cif Emergency Phone 'f 1 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No ' <br /> TYPE OF WORK(CHECK): ' NEW WELL❑­ DEEPEN ❑ RECONDITION❑ ` DESTRUCTION❑ y,.,/ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIRI <br /> REPLACEMENT❑ A, <br /> DISTANCE TO NEAREST: Septic Tank ,i 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 it Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑'DRIVEN Gauge of Casing <br /> cm <br /> 2-IRRI.GATION., �y. _ .sem' ❑.GRAVEL_PACKi,:>.:.Y.;...„T -•_Depth of.Grout Seal -- - <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ OTHER Other Information(` °" { <br /> C1 DISPOSAL � 11 <br /> �- <br /> ❑.GEOPHYSICAL ���e�_- _ Surface Seal Installed By: <br /> ��({�� <br /> PUMP INSTALLATION: Contractor fV.e,(& <br /> Type of Pump <br /> -' H.P. 0 <br /> PUMP REPLACEMENT: ❑ State Work Done = <br /> ,., . Ke- <br /> s J f <br /> PUMP REPAIR: 93'State Work Done' 's <br /> 71 <br /> DESTRUCTION OF WELL: Well Diameter I Approximate Depth <br /> Describe Material and Procedure" <br /> I hereby certify that I have prepared this application an' lhi t-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 Distric[. ' <br /> Homeowner o g r licensed agent's signature certifies the foilowing:w'jl certify that in the performance of the work for which this permit ,• <br /> is issued, I shall not employ any person in such mannerl'as to b6come 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 sfiall employ persons subject to�workman's'compensation laws of California." <br /> Iii7i all Ir a Gro speclion prior to gro ing and-a final inspection. <br /> i Date: <br /> Signed X <br /> (Draw Plot Plan on Rever Side) <br /> FOR DEPARTMENT USE ONLY - <br /> PHASE I ` <br /> Date <br /> Application.Accepted By <br /> Additional Comments: <br /> Phase 11 Grout Inspection has 11 Final Inspectio . <br /> I Inspection By Date Inspection B D to / Z <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE _1'0 EACH ❑ January 4'&Received,'By January 31 ❑ July 1 &Received By July 31 <br /> 1 �, - REMIT <br /> RASE EXPLANATION aBILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE- REMITTED AMOUNT <br /> FEE 4� �!Y r k + <br /> LESS <br /> PRORATION P ' <br /> PLUS <br /> PENALTY <br /> OTHER r <br /> OTHER - <br /> 4 <br /> ° Received by - �.-" Pate Receipt No. Permit No, - - Issua, ..Date �M.,7.dDelivered - - <br /> r <br /> I:. <br /> STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 _ <br />