Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The plication. - <br /> FQR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT 01) PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or install the work herein described.This application is <br /> l made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 6 c74 /Q City/Town <br /> Owner's Name D ORS Phone <br /> Address f ME—EiS d lel City /_/_W G'oq L,,Gel <br /> Contractor's Name ht Licens # �oB.S/ Business Phone 3�-7- CY <br /> Contractor's Address a� fee,41 Elergency Phone <br /> Is Certificate of Workman's ompensation Insuran n` il—CWit S 1_HD Yes No <br /> TYPE OF WORK (CHECK): NEW WELLZ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR IJ <br /> REPLACEMENT❑ Ln+ <br /> I <br /> DISTANCE TO NEAREST: Septic Tank S�d� Sewer Lines S�f/ Pit Privy ti4d5 <br /> Sewage Disposal Field S0^t Cesspool/Seepage Pit ��1 Other <br /> Property Lined Private Domestic Well ArqT=-�Public Domestic Well n � <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation / <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 6 S !� <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing / <br /> ❑ IRRIGATION -❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION 19 ROTARY <br /> Type of Grout ,g,,�,[� <br /> DISPOSAL ❑ OTHER Other Information -/-0 <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor !' <br /> Type of Pump H P <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 i <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 /> i <br /> Contractor's hiring or sub-cont r ing signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is Issued, I sha oy per ns subject to workman's compensation laws of California." <br /> ` t <br /> will call for a Gr nsp c lo rior to uting and a final inspection. r <br /> � d C %� <br /> + �J � 1-11AA-y tt <br /> Title: 4 � Date: g � Q I <br /> (Draw Plot Plan on Reverse Side) <br /> I <br /> F DEP TMENT E ONLY <br /> PHASE I <br /> Application Accepted By7 <br /> Q 2, Date <br /> Additional Comment <br /> P ase I o t I pection nsectiPhase III Final Inspection <br /> Inspection B -1' pon By Date - f <br /> Fee Is Due: ❑ ANNUAL "C7f7TT�� PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 l <br /> BILLING REMITTANCE REMIT <br /> DATE DATE REMITTED l <br /> BASE EXPLANATION $ 'AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE , <br /> F <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by t Date Recei t No. Permit No. <br /> Is uance 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 />