Laserfiche WebLink
A Ali t*sVIIFV'e*O(�ssW W ry ubmitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: t r (-J APPLICATION <br /> Jj0V 9 I3$(Jor Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> _ VI ONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE, V ` CT WATER QUALITY <br /> �I�OTH DISTRICT <br /> Application is hereby madetot oaquinLocalHealthDistrictforapermittoconstructand/or install the work herein described.This application is <br /> made in compliance with San Joaquin County rdinan,,No. 1862 andtherules and regulations of the San Joaquin Local Health Dis ict. <br /> Exact Site Address �r 7,33 V,�1'i/.�02yt— - fq,Y -t:• 6U'rti� 0/ k'9'��Xe_.aCity/Town �D'�• ✓t,z� <br /> Owner's Name r'�` n Phone 7�o <br /> Address f� _ City / C7 <br /> Contractor's Name y q License# c.2 L1/1 Business Phone Ll�� <br /> Contractor's Address A c1lA-9 L"IX.a 60f1 ergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes >L No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank (/)7 _r Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other /�. �?• d <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL �f <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ,ROTARY Type of Grout — <br /> ❑ DISPOSAL ❑ OTHER Other Information, 1 4 �/ f;,V Lc- <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> x <br /> Type of Pump H.P. c� <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 /> 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 /> I awilall for a GroutInsp c on prior to groutin .and a final inspection. <br /> Signed X /�. �- `Title: Date: <br /> (Draw PI Plan on Reverse ide) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � [�{� <br /> Application Accepted By �a � -`�i1 - 06 Date <br /> Additional Comments: <br /> Phase IIrUlinspection _cam Phase Ili Final I rection <br /> Inspection By Date 12-1 `4 Z- Inspection By Date 1 Z-1"796 Z_ <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ti '❑ January 1 &Received By January 31 ❑ July 1 &Received By Juiy 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED_. AMOUNT <br /> FEE ,tom <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Iss ance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />