Laserfiche WebLink
Submitted Properly Completed. BeSureTo sign 1neiappucatwr+. <br /> Applications Will Be Processed When <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable,Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health Districtfor a permit to construct and/or install the work herein described.Thisapplication is <br /> made in compliance with Sari Joaquin County Ordinance No. 1862 and th rules and regulation s:of the San Joaquin Local Health District. <br /> `t �,, .• Q�— City%Town <br /> e 0- <br /> Exact Site Address <br /> As a Phone <br /> Owner's Name city <br /> Address <br /> License# - Business hone <br /> Contractor's Name <br /> Contractor's Address J. Emergency Phone <br /> No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION.❑ WELL ABANDONMENT I] OTHER 11 PUMP INSTALLATION 13 PUMP REPAIR❑ ) <br /> REPLACEMENT❑ / Oc <br /> fSewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> OF WELL <br /> INTENDED USE TYPE 3 <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 5f DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC C3 DRIVEN Gauge of 'Casing . <br /> 11-GRAVEL PACK Depth of Grout Seal <br /> ❑ IRRIGATION <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> 13 DISPOSAL ❑ OTHER Other Information <br /> 11 GEOPHYSICAL Surfac Seal installed By: <br /> C <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> { Type of Pump <br /> PUMP RE=PLACEMENT: <br /> C3 State Work Done 4 <br /> PUMP REPAIR: 11 State Work Done t1 <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter 'C <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 kA <br /> I 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 /> t - <br /> I or a Grout Inspectio 'to.gr ng an final inspection. <br /> Title: <br /> _ Date: <br /> Signed X <br /> (DrawP of Plan on Reverse Side) t <br /> FOR DEPARTMENT USEONLY-<- <br /> PHASE t Date <br /> Application.Accepted By <br /> Additional Comments: -^ ase Ili Final In ection <br /> Phase II Grout'I -I.—, n .I0�2`L �� f <br /> �-.-. L Inspection By ate <br /> Inspection By. Date <br /> Feels Due: ❑ ANNUALLY ❑ PER UNIT ElPER SITE ❑ EACH ❑ January,1 &Received By January 31 ClJuly 1 &Receiv REMITd By uly 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> ` BASE - EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS 7 <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> i <br /> OTHER <br /> OTHER .. ., �. <br /> Date -� Receipt No.' '-- Permit No. <br /> Issu nce ate MaiSed Delivered - -; <br /> Received by <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERYICES 1601 E.�HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />