Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed._Be Sure To Sign TheApplication. <br /> . FO�� USE: /4,40f <br /> APPLICATION <br /> -� Cb-WP 14, (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) t (jjgEcv'T�/� @.2TER QUALITY p� prpp,- 09 <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 Joaquin County Ordinance No. 1862 and t rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address &� -1 #'ll A P&�.'rA Pa/317*" City/Town <br /> Owner's Name "' a' �' Phone <br /> Address d /�O-> City <br /> Contractor's Name License# 72.1—Business Phone tkC Y 77 4 74 <br /> Contractor's Address Qi:)4­42 1a Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File Wi, SJLHD? Yes _ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> I WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> ER <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 ❑ DRIVEN Gauge of Casing <br /> f ❑ IRRIGATION © GRAVEL PACK Depth of Grout Seal 4 <br /> Y ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout OC) <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> i ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. Th <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> t PUMP REPAIR:' ® State Work Done l " <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 /> i <br /> r ordinances, state laws, and rules and regulations of the San 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 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 /> 1 will call for a Grout Inspectio rior to uting and a final inspection. <br /> + Signed X itle: Date: E <br /> k (Draw Plo Plan on Reverse Side) <br /> FOR PARTMENT USE ONLY <br /> PHASEInd <br /> Application Accepted By. Date O <br /> Additional Comments: <br /> Phase Il Grout Inspection Phase III In j Inspection <br /> Inspection By Date ~ <br /> Inspection By Date P <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT VPER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 E.Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> ( BASE EXPLANATION DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS ✓ <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 1 <br /> Received by Date Receipt No. Permit No- ssuan a Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO:- ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009- STOCKTON,CA 95201 <br />