Laserfiche WebLink
a ApplicationsWill Be Processed When Submitted Properly Compl e e�n The Application. <br /> FOR OFFICE USE: APPLICATI <br /> (For Non-Transferable, Re*4% <br /> spendabl i! <br /> ENVIRONMENT TH � PUMP&WELL <br /> (COMPLETE IN-TRIPLICATE) WATE TY Q►�� � <br /> Application is hereby made to the San Joaquin Local Health District for a per o construct a � <br />{ made in compliance with San Joaquin Counly Ordinance No. 1862 and the rules an1. work herein described.This application is <br /> Exact Site Address j. the San Joaquin Local Health District. <br /> Owner's Name h—Q' /' `City/Town�i; K f <br /> Address 1 Phone �I�'[ r '` ,�3 `` <br /> Contractor's Name � � <br /> one <br /> Lice ! <br /> Contractor's Address �� 7 nse#�-7— Business Ph9 1 <br /> "� Emergency PhoSneZ/—`f 13o �a "569 il2._ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN 11 RECONDITION No <br /> ❑ <br /> WELL CHLORINATION pESTRUCTION❑ <br /> ElWELL ABANDONMENT ❑ OTHER El PUMP INSTALLATION"❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> Il <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines ;'-� <br /> Pit Privy <br /> Sewage Disposal Field <br /> Cesspool/Seepage Pit p �— <br /> Property Line � Other <br /> Pro <br /> P yQ — Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL Pf J� <br /> CABLE TOOL Dia, of Well Excavation la 4S� f it <br /> I� DOMESTIC/PRIVATE ❑ DRILLEDs+ <br /> ❑ DOMESTIC/PUBLIC Dia. of Well Casing <br /> ❑ DRIVEN Gauge of Casing I`z !A <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 510 e <br /> ❑ CATHODIC PROTECTION ❑ ROTARYII <br /> ❑ DISPOSAL ❑ OTHER Type of Grout 'Sk 1'� w t # <br /> El GEOPHYSICAL Other information <br /> PUMP INSTALLATION; Surface Seal Installed By: ia'- fe <br /> Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done H <br /> n <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter ���Ap`pr600xite Depth <br /> Describe Material and ocedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> t <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:"l certify that in the performance of the work for which this f <br /> permit is issued, 1 shall employ persons subject to workman's compensation laws of California." � <br /> I will cfIVor a Grout Inspection prior to grouting and a final inspection. <br /> Signed X is <br /> Title: —_�') / iI Date: orf �T <br /> raw Plot Plan on Reverse Side) �i <br /> FOR DEPARTMENT USE ONLY r <br /> PHASE I <br /> F <br /> pplication Accepted Bydy'll l C-C,12 �( p <br /> dditional Comments: Date <br /> ------------------------- <br /> Il <br /> Phase II Grout Inspection7 <br /> Inspection By Phase 111 Final Inspection <br /> Date Inspection By ��]�-tEitte -4 5 � <br /> Fee Is Due: ❑ PER UNIT ❑ <br /> ANNUALLY �I Y <br /> ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 8 Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE REMIT y <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE � — <br /> AMOUNT 1 <br /> LESS J. <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER F <br /> Received by Datei <br /> Receipt No. Permit No, Issua ce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HA2ELTON AVE.,P.O.Bar 2009 crnrrrnu <br />