Laserfiche WebLink
ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign TThe App_lfcation. <br /> FOR oF�fcE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> I <br /> 2! (For ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <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 a oaq nt in a 1862 and the rules and regulations of the San Jo in Local�f le fth District. <br /> Exact SiteAddres �� itf0- <br /> City/Town C c /z'i-1 <br /> Owner's Name Phone <br /> Address <br /> � <br /> Contractor's Name YCityicense# <br /> usiness Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insur ce on File With SJLHD? Yes��� No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 1J <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank r 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 /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> &-15OMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN <br /> Gauge of Casing n _ <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal C✓ <br /> ❑ CATHODIC PROTECTION ❑ ROTARY <br /> ❑ DISPOSAL Type of Grout <br /> ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION. Contractor �i CL�v,S G �� - <br /> Type of Pump P /- <br /> PUMP REPLACEMENT: ❑ 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 dome in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Healtb,District,_ <br /> Homeowner 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-pe-r'f-ormance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of Califo " <br /> I will call for a Grout Inspection prior to grouting and a final inspection. / <br /> Signed X Title: i�'-` f� <br /> �z!� Date: <br /> (Draw Plot Plan on Revers Side) k <br /> PHASE IFOR DEPARTMENT USE ONLY t <br /> fi�... a <br /> Application Accepted By \ _ Date 1 <br /> Additional Comments: <br /> Phase it Grout Inspection i <br /> �einaispection fInspection By Date Inspection ByDate 12 <br /> i <br /> .Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 El July 1 &Received By a 31 A� <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT �• <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> SFEE AMOUNT <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by - Date Receipt No. Permit No. Iss anc Date <br /> Mailed Delivered 3 <br /> APPLICANT—RETURN ALL COPIES TO: -ENVIRONMENTAL HEALTH PERMITISERVICES <br /> 1601 E.HAZELTON AVE,,P.O.Box 2009 S70CKTON,CA 95201 <br />