Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION ! <br /> (For Nan-Transferable,'Re vocable,5uspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> COMPLETE IN TRIPLICATE WATER QUALITY:. <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work,herein described.This application is <br /> made incompliance with San Joaquin County rdinanc o. 186.2 and Jthe errules and regulations of the San oaqu n Local Health District, <br /> Exact Site Address 73d � ,��-^� City/Town <br /> VV c" f <br /> Owner's'Name � Phone• :C - -13 --�• . <br /> Address / 3 <br /> Contractor's Name p /� � License#IG11 7 R. Business Phone 2c. <br /> Contractor's Address / 0 Emergency Phone `+ (C 6.-2-4— L <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes `� No <br /> TYPE OF WORK (CHECK): NEN_WELL❑ DEEPEN ❑ RECONDITION❑-- DESTRUCTION❑ <br /> WELL CHLORINAT)ON ❑ WELD ABANDONMENT ❑ - OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENTIT <br /> DISTANCE TO NEAREST: Septic Tank \Sewer Lines Pit Privy <br /> ,.Sewage Disposal Field `_ "Cesspool/Seepage Pit Other <br /> Property Line Private Domestic=elI Public Domestic Well <br /> INTENDED USE TYPE OF WELL _ <br /> ❑ INDUSTRIAL m ❑ CABLE-TOOL Dia. of Well Excavation <br /> �MESTIC/PRIVATE ❑ DRILLED ; % Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing - <br /> ❑ IRRIGATION # ❑ GRAVEL PACK fi Depth of Grout Seal.' <br /> - <br /> ❑ CATHODIC PROTECTION ❑ ROTARY ji.+°? Type of Grout 1 r <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL #. Surface Seal Installed By:- <br /> PUMP INSTALLATION: Contractor 1' <br /> Type of Pump T H.P. <br /> PUMP REPLACEMENT: EI State Work Done <br /> PUMP REPAIR: � 1, ❑ State Work Done <br /> DESTRUCTION OF WELL: ` Well Diameter 1 Approximate Depth – 7_ <br />!I 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 /> Home owner or licensed agent's signature.certifies the following:"I certify that in the performance of the work forwhich 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 1 <br /> permit is issued; 1'.1shall employ persons subject to workman's compensation laws of California." i <br /> I will I for a Grout IVpect1oin pnordo grouting and a final Inspection. <br /> Signed.X- 14 �Tille:, /�j'1/l� --Date:. <br /> i (Draw Plot Plan on Rever Side) <br /> }. FOR DEPARTMENT'USE ONLY I` 4 <br /> PHASE I i – - f t:F.......- <br /> Application Accepted By Date <br /> Additional Comments:] <br /> - Phase II Gr inspection - t � � � Ahase 1 a1 Inspection 1 <br /> Inspection By - `j bate j AI sn pection By Date � ✓ <br /> r <br /> e Y <br /> Fee IS Due- CI'ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE. <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE, REMITTED AMOUNT <br /> FEE <br /> r � j X46 <br /> - <br /> LESS <br /> PRORATION t ' <br /> PLUS <br /> PENALTY <br /> OTHER - f <br /> ! <br /> OTHER <br /> Received by Date Receipt No. .Permit No..., I.Issuancel Date Mailed Delivered y <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON.CA 95201 <br />