Laserfiche WebLink
Applications Will Be ProcessedWhenSubmitted Properly completed. BeSureToSign TheAppllcauon <br /> 'CE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable} f <br /> r - 1 PUMP&WELL <br /> ---- ENVIRONMENTAL HEALTH PERMIT <br /> TE IN TRIPLICATE) WATER QUALITY <br /> ;cation 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. 18_q2 and the and regulations of the San Joaquin Local Health District.Exacl Site Address ►'�_._W)W lII4 &.V9 & 4C. City/Town <br /> wo of <br /> Owner's Name Phone __ '7�'� <br /> Address ?� _ city--6,40 /� <br /> Contractor's Name �' G" .�� License #� 3.i�Business Phone_ Y rl t: 7 6 <br /> Contractor's Address 6fll AV Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With HD? Yes No /� <br /> TYPE OF WORK (CHECK): NEW WELL 13 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 0 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR; r <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy J <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 /> 0 <br /> xcavation ___❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 9 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. D <br /> PUMP REPLACEMENT: ❑ State Work Done _.. <br /> PUMP REPAIR: _'State Work Done • <br /> DESTRUCTION OF WELL: Well diameter Approximate Dep h <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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will cfill for a Grout Inspection r outi and a final inspection. <br /> Signed X file: Qr�i Date: <br /> /"& <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE [ oD Date G"Pe <br /> ` <br /> Application Accepted By <br /> Additional Comments: ---- <br /> Phase II Grout Inspection iP s I F' Inspection <br /> Inspection By Date Inspection By / Date Z <br /> Fee IS Due: ❑ ANNUALLY ❑ 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 ARITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 1113 _ <br /> Received by Date Receipt No Permit No, Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENWRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />