Laserfiche WebLink
f <br /> Applications Will Be Processed When Submitted Properly o � , i <br /> APPLICATION :��' �� <br /> FOS OFFICE USE: (For Non-Transferable, RevacableF�►� rlb e? PUMP&WELL <br /> ENVIRONMENTAL H ERMIc <br /> WATER QUAL <br /> .(COMPLETE IN TRIPLICATE) toc dein described.This application is <br /> Application is herebymadetotheSanJoaquin IHealthDistriReezM fi2a dora phe rulesand reg ulorl9oE"a"e o1�in ocal istrict? <br /> e in corn liance wit o ount r "na <br /> mad A �� wn <br /> Exact Site Addres V <br /> + Phone <br /> Owner's Nam City <br /> Address nse# Buses�?hOn 1 t <br /> Contractor's Name C� <br /> Emergency Phone <br /> Contractor's Address No f}(} <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ❑ pESTRUCTION13 v �s <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION � / <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHERS❑- PUMP INSTAMATIO lids PUMP REPAIR❑ <br /> REPLACEMENT❑ Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other <br /> Sewage Disposal Field public Domestic Well <br /> Property Line Private Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ CABLE TOOL Dia. of Well Excavation <br /> 11 INDUSTRIALDia. of Well Casing <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED <br /> Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC C1 DRIVEN❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ IRRIGATION Type of Grout <br /> ❑ CATHODIC PROTECTION ❑ ROTARY <br /> ❑ DISPOSAL ❑,OTHER Other Information <br /> ace Seal Installed By: <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION- Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: <br /> Well Diameter <br /> Describe Material and Procedure <br /> 1 <br /> rdance with San Joaquin County <br /> I hereby certify that I have prepared this application and that the work will be done in acco <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 fallowing:"I certify that in the performance of the work for which this permit <br /> is issued, I shall no ploy any person in such manner as to become subject to workman's compensation laws of rwhi California." <br /> Contrac*FR! <br /> signature certifies the following:"I c ify that in the performance of trie work forwhich this <br /> Per <br /> I �1s subject to workman's compens Ion laws of California." <br /> r grouting and a final ins <br /> Title: Date: <br /> Signed X (Draw Plot Plan Reverse Side) t. <br /> FOR DEPARTMENT USE ONLY 2 <br /> " PHASE I Date —�``'A�I <br /> Application Accepted By <br /> Additional Comments: phasq 111 Final Inspection <br /> Phase 11 Grout Inspection Date <br /> inspection By , <br /> Date <br /> Inspection By . <br /> ❑ PER SITE ❑ EACH El January 1 &Received By January 31 ❑ July 1 &ReceiveRd EMI By July 31 <br /> Fee Is Due: C1 ANNUALLY C3 PER UNIT <br /> k - BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT. <br /> I � <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> y OTHER <br /> FI ribs Issuance Date Mailed Delivered <br /> [ Date Receipt No. ermit No. <br /> ;' Received by 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERYIGES . <br />