Laserfiche WebLink
;f.rspllcations Will Be Processed When Submitted Properly Completed. Be Sure To Sig�e Applicatio . <br /> APPLICATION � <br /> (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> f <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 the work herein described.This application is <br /> made in compliance ith San Joaquin C my Ord- nce No. 1882 he rule <br /> Exact Site Address s and regulations of the San Joaquin Local Health District. <br /> 4 CC. <br /> r O �^ City/Town �� C00,f, C <br /> Owner's Name - <br /> Address Phone <br /> Contractor's Nam City <br /> PL ��icense d s Business Phone Y .mo i <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insura eon File With SJLHD? <br /> TYPE OF WORK (CHECK): NEW WELL L-1— ❑ RECONDITION DESTRUCTION❑ <br /> i <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION Com"PUMP REPAIR❑ � <br /> REPLACEMENT❑ ( .1 <br /> DISTANCE TO NEAREST: Septic Tan Sewer Linesl!" <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 /> ❑ IND STRIAL ❑ CABLE TOOL <br /> ,- - � Dia. of Well Excavation <br /> LEV-DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing (a s 8 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing / <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal U <br /> ❑ CATHODIC PROTECTION 9-O RY <br /> DISPOSAL Type of Grout <br /> ❑ OTHER Other Informationp , <br /> � GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> - a <br /> Type of Pump H P <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> �i <br /> Describe Material and Procedure Approximate Depth i I+ <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 /> �q <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 orsub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> ermit is issued, I shall employ per subject to workman's compensation laws of California." r <br /> w call for a Grout I ' <br /> pe to prI r to routing and a final inspection. <br /> Signed X Title: cafF �, <br /> r!YV G'(n Date: <br /> Draw Plot Plan on Reverse Side) t <br /> PHASEI r <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted By �� +-5 y,, ❑ <br /> Additional Comments: DateAasl _ <br /> e 11 Grout Inspection J YIE1, <br /> ase IIIincl Inspection <br /> Inspection Date /� Inspection ByDateFee Is Due: ❑ NUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &ReJanuary 31 ❑ July 1 &Received By JUiy 31 <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 /> m <br /> Received by ate <br /> �Receipt o. Permit No Issuance Date Mailed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES Delivered <br /> 1fi01 E.HAZELTON AVE.;P.O.Box 2009 STOCKTON.CA 9520*'A2r <br />