Laserfiche WebLink
ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. . <br /> FOR OFFICE use: APPLICATION -o T-- i (3 <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 per tOCOnstruct and/or install the.work,herein described. s application is <br /> made in compliance with-San Joaquin Co t Ordinance No. 1$6�and the .rules and regulationThi <br /> s of the San.Joaquin Local Health District. <br /> Exact Site Address - ' <br /> f City/Town _ <br /> /p i <br /> Owner's N :D <br /> ame ;?_ , � w �..,�� •� r�C �-` <br /> f Address one_ :- <br /> 1; 7�{ : city:,. <br /> ' Contractor's Name <br /> ` G --' License' - Phone. <br /> Business _ l <br /> k, Contractor's Address � � .�• - - •. � <br /> .. Emergency Phone �` „p . j y y > <br /> I Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF 1NORK (CHECK): NEW WELL❑ No — <br /> DEEPEN ❑ RECONDITION❑ DESTRUCTION❑- :.. Cn <br /> WELL-CHLORINATION ❑ WELL ABANDONMENT ❑ -'OTHER ❑ PUMP INSTALLATION Q—PUMP-REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines <br /> 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 />` ❑❑ IN�STRIAL ❑ CABLE TOOL <br /> i�DOMESTIC/PRIVATE El DRILLED <br /> of Well Excavation. <br /> DRILLED Dia. of Well Casing <br /> 13 DOMESTIC/PUBLIC ❑ DRIVEN <br /> 11IRRIGATION � ❑ Gauge of Casing <br /> GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY <br /> ❑ DISPOSAL Type of Grout -� <br /> ❑ OTHER Other Information j <br /> ❑ GEOPHYSICAL ` Surface Seal Installed By: t <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump, - H P <br /> PUMP REPLACEMENT: 1State Work Done <br /> PUMP REPAIR: ❑iState Work Done <br /> DESTRUCTION OF WELL: Well Diameter ,...# <br /> � Approximate Depth <br /> Desctibe Material and Procedure_ <br /> 1 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 will call for a rout Inspe tl prior to grouting and a final inspection. «� <br /> Signed X - Title: <br /> .Date: <br /> (Draw Plot Pian on RevPre Side) <br /> FOR DEPARTMENT USE ONLY r <br /> PHASE I Y " <br /> Application Accepted By L � <br /> Additional Comments: Date <br /> Phase 11 Grout Inspection <br /> ,,P�h�41inal-InspectionInspection By t Date Inspection By ✓r Date � � <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑-EACH <br /> ❑ January.l 8 Received By Januar31 ❑ July 1 &Received By July 31 <br /> BILLINGREMIT r <br /> BASE EXPLANATION fWAMOU.NT <br /> DATE DUE CHECKEDFEEAMOUNTLESS <br /> PRORATIONPLUS <br /> PENALTY <br /> QTHEROTHER # ; <br /> Received by s - 4 /� "r •� �_ <br /> ReceipfNo. - Permit No.--F - - ssuance ate -- Mailed• -- <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PEgMIT75ERViCES Delivered - <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />