Laserfiche WebLink
$. Applications Will Be Processed When SubmittedProperlyt,o } <br /> APPLICATIO _ 1 4 <br /> KM <br /> PUMP&WELL <br /> (For Non-Trarisierable,Revocablendj�Ijj 3 0 1981 <br /> ENVIRONMENTAL HEALTH PER <br /> WATER QUALITY SAN J01'.0U!N LOCAL application is <br /> (COMPLETE IN TRIPLICATE} r n described.This app <br /> r11t1 ss ict. <br /> Application is hereby made to the San JoaquinLacalHealte Dostr8�tforap�rmit to <br /> regulations of the Sane <br /> made in-compliance wit} ;6 j an Co� City/Town yC <br /> Exact Site Address / a17 �— <br /> Er 1'` Phone �) <br /> Owner's Na L— gcitv <br /> Address v� S License# / 7t3 ine�ne <br /> Contractor's Name �j �emergency Phone ' <br /> Contractor's Address No <br /> Is Certificate of Workman's ComIVE1Ns1NELLion l❑uranDEEPEN 11 ith SR CONDITION❑ DESTRUCTION❑ <br /> TYPE OF WORK (CHECK): ,�,/ 1 s <br /> CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER LN' PUMP INSTALLATION ❑ PUMP REPAIR <br /> WELL CHLOR N <br /> REPLACEMENT❑ Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank C <br /> Sewer Lines <br /> esspool/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 /> ❑ INDUSTRIAL 13 DRILLED Dia. of Well Casing <br /> ElDOMESTIC/PRIVATE Gauge of Casing <br /> ❑ MESTIC/PUBLIC E) DRIVEN <br /> ❑ GRAVEL PACK Depth of Grout Seal <br /> LJ IRRIGATION ❑ ROTARY Type of Grout <br /> ❑ CATHODIC PROTECTION ❑ OTHER Other Information <br /> i ❑ DISPOSAL Surface Seal Installed By. <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor qF7 <br /> Type of Pump <br /> Le State Work Done , <br /> PUMP REPLACEMENT: ❑ State Work Don ' <br /> PUMP REPAIR: D pproxtmate Dept <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> at the{ one Ob <br /> I hereby certify that I have prepared regulatonstio the San Joaquin oLocal rk llHealtbe h District.accordance with San Joaquin County <br /> ordinances, state laws, andy that in the <br /> Home owner or licensed agent's�Slgn6ture such mannerfifies the cerastogbecomefsubject to workman'S compensation for <br /> of Cal forn aft <br /> is issued, I shall not employ y P v <br /> ( or sub-co ng signature certifies the following:"1 certif that in the performance of the work forwhich this -----iiiii <br /> Contractors g <br /> t p I IS ' d, I sh II empl y per ons subject to workman's compensate aws of California." � <br /> 1 wil 11 r Inspecti pri t r ting nd a final inspection <br /> Date: <br /> Title: <br /> Signed X (Draw Plot Plan on everse Side) <br /> FOR DEPARTMENT USE ONLY <br /> ` C` `�-- <br /> PHASE I Date <br /> j Application Accepted By <br /> j Additional Comments: P. -JI ll Inspection 4 <br /> f hese Il Grout Inspection ` _Date y�r <br /> 4 Date inspection By <br /> i inspection By <br /> El PER UNIT ❑ PER SITE ❑ EACH ❑ January &Received By January 31 ❑ July 1 &Received By July 31 <br /> FEB IS DUB: ❑ ANNUALLY <br /> BILLING R E $ AMOUNT DUE CHECKED <br /> s <br /> BASE EXPLANATION DATE REMITTED AMOUNT <br /> FEE y <br /> LESS ' <br /> PRORATION <br /> PLUS v <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 3 <br /> Receipt No Permit No. <br /> Is uanc Date Mailed Delivered <br /> Received by Date teat E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> ' — APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES — <br />