Laserfiche WebLink
T <br /> Applications Will Be Processed When Submitted Properly Completed.Be Sure To i e tl I IGa� 1981 <br /> FtR OFFICE use: APPLICATION 1Y" I7 <br /> (For Non-Transferable, Revocable, Suspendable) PUMP 8F <br /> C , , � LOCAL <br /> ;. <br /> ENVIRONMENTAL HEALTH PERMIT SAN JHEALTH DISTRICT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <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 with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San JoaquinLocalHealth District. <br /> ' ? City/Town <br /> Exact Site Address ��r q 9Q <br /> sO A1r iWf, !L/ %`t Phone <br /> Owner's Name Cit L �� <br /> Address 1 /�nr y <br /> �J ' t37 l <br /> Contractor's Name � � �� License#s��®/� BusinJ�es��e � <br /> ��� � ��lw Emergency Phone - <br /> Contractor's Address Yes A&L�-.— <br /> � No <br /> Is Certificate of Workman's Compensation_Insurance on File With SJLHD? <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT® „,4 <br /> DISTANCE TO NEAREST: Septic Tank <br /> Sewer Lines Pit Privy <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 /> ElDOMESTIC/PUBLIC <br /> i ! # j❑ 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 /> 11 GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> j PUMP REPLACEMENT: 2.State Work Done knt { IV <br /> PUMP REPAIR: ❑ State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> .Describe Material and Procedure <br /> w : <br /> I hereby certify that I have prepared this application and that the wor vk1 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:1 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 forwhich this ` <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I w' II for a Grout s ectio prior to grouting and a final insp n. L <br /> Title: Date: <br /> Signed X. t <br /> (Draw Plot Plan on everse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 Date—67 <br /> Application Accepted By ` <br /> Additional Comments: IIS Final Inspection <br /> Phase 11 Grout Inspection o <br /> Inspection By <br /> Date Inspection Date <br /> Fee Is Due: [D ANNUALLY [3 PER UNIT El PER SITE ElEACH ❑ January i &Received By January 31 El 1 &Receive <br /> REMIT <br /> ft d By uIy 31 <br /> BASE EXPLANATION :BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 0 45 <br /> LESS <br /> I PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> k - Issuance Date Mailed Delivered <br /> Received by - Date Receipt No. PSE.RVICE - _ <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZELTON AVE.,P.O.box 2008 STOCKTON,GA 95201 <br />