Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE. APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) 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 thework herein described.This application is <br /> made in compliance with San Joaquin County Ordinancy No. 1,862 and the rpl s and regulations of the San Joaquin Local Health District. <br /> Exact Site Address { ' "°' -`" " ' " V- Cit /Town <br /> r1-r' fl,Aaie. f•.. ;. rS r-,f .•.r r, <br /> Name !1 i J',% 'f,t ,. Phone <br /> Owner's E.l <br /> Address :l Ifr�� 1 c City <br /> Contractor's Name License#- ' Business Phone <br /> Contractor's Address '''" ai a' Emergency Phone <br /> • O <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes i No <br /> TYPE OF WORK (CHECK): NEW WELL El DEEPEN 11RECONDITION❑ DESTRUCTION 0]. <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIdN-E "-PUMP REPAIRO <br /> REPLACEMENT 0 4 j <br /> DISTANCE .TO NEAREST: SepticTank "r Sewer Lines Pit Privy <br /> t _— <br /> A tSewage,Disp�sal Fiehd(� - Cesspool/Seepage Pit Other <br /> Property Line_• Private Domestic Well Public Domestic Well <br /> . p Y � J-�, �. ' <br /> INTtNDED USE ` TYPE aF WELL <br /> ❑ INDUSTRIAL c�v�+ 1f-( •.} '0 CAE't <br /> 6LOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 3 <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal•` <br /> 13 CATHODIC PROTECTION 11 ROTARY w 'Type of Grout' I <br /> ❑ DISPOSAL ❑ OTHER +,Lk Other Information <br /> ❑ GEOPHYSICAL ,t Surface Seal Installed By: i <br /> PUMP INSTALLATION: pnira'cfor <br /> "Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> f] State Work De ' • , ... ��: : <br /> PUMP REPAIR: on ,• ; <br /> DESTRUCTION OF WELL: Well Diameter' Approximate Depth <br /> De,611be.Ma'terial and Procedure <br /> s <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 o 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 fallowing:"I certify that in the perform bnce of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I <br /> !- itl•calLfaw a-Gro t;lnspefption•prior to grouting•and a final-inspection. ,� <br /> Signed X Title: a'. µ Date: <br /> (Draw Plot Plan on Reverse Side) <br /> li <br /> I FOR DEPARTMENT USE ONLY <br /> PHASE 1 <br /> Application Accepted By '"'� ^" } �'" y�a� ""- Date <br /> Additional Comments: f <br /> Phase II Grout Inspection Phase II1 Final Inspection <br /> Inspection By <br /> Date Inspection By Bate <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 $ �'.iAMOURT DUE CHECKED . <br /> DATE DATE REMITTED AMOUNT,' <br /> � Y <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> w� <br /> OTHER <br /> OTHER <br /> I� 7 <br /> t�-7`1 G) O_�0-t"Z-4 o <br /> Received by Date Receipt No. Permit No. Iss ante 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 />