Laserfiche WebLink
•• � ­V1111«"TU r-raperr completed. Be SureTo Sign The Application. <br /> Fob oFFlr �sE: APPLICATION <br /> (For Mon-Tran§ferable, Revocable,Suspendable) <br /> -1 - ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) ' WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance wit San Joaquin.0 unty Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address <br /> City/Town <br /> Owner's Name '/�z <br /> Address <br /> Phone � <br /> - � <br /> i� <br /> Contractor's Name City License#�Q/ - �_ �r_�lVc� <br /> Business Phone_ <br /> Contractor's Address Emergency Phone <br /> Is Certrficate of Workman's Compensation In urance on ile With SJLHD? Yes_ <br /> TYPE OFYWORK (CHECK); NEW WELL^ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER Cl PUMP INSTALLATION ❑ PUMP REPAIR❑ 1 <br /> REPLAC��MENT 1:1 <br /> DISTAGI TO NEAREST: Se tic Tank <br /> p Sewer Lines Pit Privy <br /> Sewage Disposal Field 100 -' Cesspool/Seepage Pit <br /> Other <br /> Property Line Private Domestic WellPublic Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL <br /> ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLER Dia. of Well Casing 01 a�G <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ` <br /> ❑ IRRIGATION MOTARYType <br /> RAVEL PACK Depth of Grout Seal (,y <br /> ❑ CATHODIC PROTECTION of Grout `F <br /> DISPOSAL r. <br /> ❑ OTHER Other Information Q �J <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump q <br /> H.P. <br /> PUMP REPLACEMENT: C1 <br /> State Work Done <br /> PUMP REPAIR: ❑ state Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <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 /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> will all fora Grout nsp ti prior to gro ting and a fin I ins eciion. <br /> Signed X Title: <br /> Date: <br /> (Dr lot Plan on Rev rse Side) J <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> Application Accepted By e_�� <br /> Additional Comments: Dat �f <br /> e II Grou spection III Final spection�' <br /> Inspection By ate t7 — inspection By <br /> to <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMfT <br /> DATE i, DATE REMITTED AMOUNT DUE CHECKED <br /> FEE <br /> AMOUNT <br /> �' � � . <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> w....� j <br /> OTHER <br /> i <br /> Received by D to Receipt No. Permit No. <br /> APPLICANT—RETURN ALLCOPIESTO: ENVIRONMENTAL HEALTH"PERMIT/SERVICESIssuance Nate Mailed Delivered } <br /> 1801 E.HAZELTON AVE.,P.O.90■2009 STOCKTON,CA 95201 <br />