Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completefi$"S <br /> j�SuF Sgn epp <br /> } atl <br /> FOR`OFFICE USE: APPLICATION So <br /> - <br /> (For Non-Transferable, Revocable, Suspele} <br /> ENVIRONMENTAL HEALTH PERMITJUN 2 �9$� PUMP WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY �, 11 C <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/oS5�IAF)e rk para cl ed.Thisapplicationis <br /> made in compliance with San Joaquin ounty Ordinance No. 1862 and the rules and regulations of ffie`�an Joaquin Cocal Health District. ' <br /> Exact Site Addressc� � � City/Town <br /> Owner's Name d Phone / . <br /> ' `7 <br /> Address .j �^' City <br /> Contractor's NameC' Li ense# �l usiness"Phone ' <br /> Emergency Phone r�� <br /> Contractor's Address � , <br /> Is Certificate of Workman's Compensation frisurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATi ❑ 11WELL ABANDONMENT ❑ OTHER PUMP INSTALLATION ❑ PUMP REPAIR❑ f <br /> REPLACEMENT 1 <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy W 1 <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 /> DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ' <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ' <br /> Type ump H.P. <br /> PUMP REPLACEMENT: State Work Done -OY-71Z <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth t <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 <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health 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 /> 1 Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> j permit i ed, I shall employ persons subj t to wor man's compensation laws of California." <br /> I I call f a Grout Inspection or to gr ting a final inspection. <br /> Signed X Title: Date: <br /> (Dr w Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> 4- PHASE I Q� Date <br /> Application Accepted By <br /> E Additional Comments: N" <br /> 1 Phase 11 Grout Inspection ha I11 F'nal Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> 7REM4T <br /> I BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> Il PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by - Date Receipt No. Permit No. Issuance Date Mailed Delivered - 4 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2099 STOCKTON,"CA 95207 <br />