Laserfiche WebLink
Applications Will Be ProcessedWFien Submitted Properly Completed.Be Sure To Sign The Application. <br /> FOR OFF)CE USE: APPLICATION <br /> .� (For Non-Transferable, Revocable,;Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY ,0 t to Q! P2„ <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instal I,the work,herein described.This application is <br /> made incompliance with San Joaquin.County Ordinance No.-1862 and"the*rules and.regulations of the San Joa uin oc I Health District. , <br /> Exact Site Address S� City/Town CIzz <br /> Owner's Name '� � ��/� Phone 1 7 S� <br /> Address City „ .., . <br /> Contractor's Name � " '� to License# Business Phone <br /> sr <br /> Contractor's Address "` ^' '` Emergency Phbne <br /> Is Certificate of Workman's Compensation Insurance on File-l+,Vith SJLHD? , Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN 11' RECONDITION -DESTRUCTION❑ Y <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Ca") Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br />'I Property Line - Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ` <br /> VDOMESTIC/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 s ` <br /> ❑ GEOPHYSICAL Surface Seal Installed By:- <br /> PUMP INSTALLATION: Contractor _ <br /> Type of Pump _ H.P. W 5 <br /> PUMP REPLACEMENT: C1 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 /> r <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 theperformance 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> l ill call for Gro Inspection prior to grouting and a final inspection. - r <br /> Signed X _ Title: �W -- Date: <br /> (Draw Plot Plan on Reverse Side) l <br /> FOR-DEPARTMENT USE ONLY t '� <br /> l PHASE I ` � <br /> Application Accepted By C0 Date �I <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br />�- - Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER"SITE ❑ EACH' ❑ January 1 S Received By January 31 ❑ July 1 S Received By July 31 <br /> REMIT <br /> BASE EXPLANATION F BII LING REMITTANCE $ AMOUNT DUE CHECKED <br /> BATE DATE REMITTED AMOUNT <br /> t <br /> 3 FEE <br /> LESS <br /> PRORATION C <br /> PLUS ` <br /> PENALTY <br /> r OTHER - - - - <br /> air- <br /> I OTHER <br /> Received by Date - " Receipt No. Permit No, - Issuance Date Mailed - Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 0rA <br />