Laserfiche WebLink
f Applications-V llf-Be-fes car essed When Submitted Properly Completed:Be Sure To Sign Th Application. <br /> pplication. <br /> FOR OFFICE USE: <br /> APPLICATION <br /> (For-Non-Transferable, Revocable;Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT , <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> f Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and�/or inst"llih,e work herein described.This application is <br /> a made in compliance with San ioaiWjn County Ordi!t ce No. 18 2 ani,the rules and regulations of the San Joaquin Local Health District. <br /> r Exact Site Address _ City/Town <br /> Owner's NamkeS� c; <br /> Address r1 ['i >. ^ Phone � � <br /> c; City W <br /> Contractor's Name - —} <br /># " License#�� Business Phone_ <br /> Contractor's Address '= i .rl� T✓73z -• M Emergency Phone J <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No ' <br /> TYPE OF WORK (CHECK): NEW WELL 11DEEPEN 13RECONDITION❑ ' DESTRUCTION,❑ <br /> El CHLORINATION WELL ABANDONMENT ❑ OTHER El PUMP INSTALLATIONu, PUMP REPAIR 11 <br /> REPLACEMENT❑ _ <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 /> ❑ INPdSTRIAL b 13CABLE TOOL Dia. of Well Excavation <br /> L-?-DOMESTIC/PRIVATE ❑ DRILLED Dia- of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ ; <br /> GRAVEL PACK Depth of Grout Seal i; <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: ._...' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. i <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Dane I <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure f <br /> I hereby certify that I have prepared this application and that the work'wiN,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 /> -wi r Grout InspRction prior to grouting and a final inspection. <br /> Signed y Gz <br /> Title: _ n � Date: r L J <br /> (Draw Plot Plan on Reverse Side) <br /> . i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspections I Final Inspection Com` <br /> Inspection By Date Inspection By Date "2 7 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH' ❑ JanuaryReceived B <br /> 1 &RJanuary Y 37 ❑ July 1 &Received By July 37 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED 'AMOUNT DUE CHECKED <br /> FEE AMOUNT <br /> LESS <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 4batb <br /> Received by DateReceipt No. Permit No. Iss Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 I <br />