Laserfiche WebLink
ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION �rY9 <br /> �! (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <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 w h San)oaquin Copnty Ordi58nce No. 1862 cvd the rules and regulations of the San oaq 'n Local Health District. <br /> Exact Site Address i6 OS City/Town ff <br /> Owner's Na e Phone d6z <br /> Address City <br /> Contractor's Name License# Business Phone <br /> Contractor's Address 4 Emergency Phone <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes N <br /> PAIR❑ <br /> TYPE OF WORK (CHECK): NEW WELL El DEEPEN El RECON ITION❑ DESTRUCTI <br /> 13 �rV�C <br /> WELL CHLORINATION WELL ABANDONMENT ❑ OTHER PUMP INSTALLATION PUMP R <br /> REPLACEMENT 11 .0 <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 /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> _ ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surfa�qe Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump i <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 /> Homeowner 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 fo a Grout Inspection prior to grouting 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 By Date <br /> Additional Comments: ' <br /> Phase II Grout Inspection Phase't at Inspection <br /> Inspection By Date Inspection Byate <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECK <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE svI,, 5 4 0 D <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> \�o -s--9-1 a ! kz�,`CZE 1.-. --5 --x ti <br /> Received by Date Receipt No. Permit No.. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 ,/ <br /> 1 <br />