Laserfiche WebLink
Applications—Will Be ProcessedWhen Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR oFFlcs usE:�- - APPLICATION <br /> ' (For Non-TransTiableelrocable, Suspendable) <br /> - ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> I ` <br /> F (COMPLETE IN TRIPLICATE)— WATER QUALITY <br /> r Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or install the work herein described.This application is <br />` made in compliance with San Joaquin Co my rfinance No.'1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address o City/Town �� j �/� <br /> • E `� / �. <br /> F Owner's Name �C' / f✓ Phone p <br /> j Address 30 /. .®C6�lc' Ra City ��l?I I <br /> Contractor's Name G� License Business Phone <br /> Contractor's Address �=G /�." �C'1� Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL, DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> i WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank /fes Sewer Lines Pit Privy --- <br /> Sewage Disposal Field <Cesspool/•Seepage Pit '+;" 3 Other y y <br />[ Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPEOF <br /> ❑ INDUSTRIAL CABLE TOOLS Dia. of Well Excavatin <br /> A" DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well <br /> Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> T❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type o Grout <br /> ❑ DISPOSAL ❑ OTHER Other Informatio I <br /> ❑ GEOPHYSICAi # r <br /> _ Surface Seal Installed,By: F <br /> s PUMP INSTALLATION:;4� Contractor <br /> Type of Pump - Votir H.P. <br /> PUMP REPLACEMENT: ❑ State Work Don s I ) <br /> PUMP REPAIR: State <br /> Work Done <br /> DESTRUCTION OF WELL: Well Diameter t / `ll <br /> t..._,C Approximate Depth <br /> Describe Material a_rid PrrocedTre 1 t <br /> I hereby certify that I have prepared this application and-that-the-work-will-be--done ii�,hccordance with San Joagtain 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 ollowin_g"I ce ify that�in the performance of the work for which�this permit <br /> is issued, ! 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 oil wing AIS 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 /> I will ca for a Grout Inspec ' n,prior to routing and a final in pec ion. <br /> Signed X �`' ` ►r ` 1 <br /> Title: Datet d � <br /> (Draw Plot Plan on Reverse Side) + <br /> FOR DEPARTMENT USE ONLY <br /> . PRASE I ��q� <br /> Application Accepted Byg, Date �+do~"� <br /> Additional Comments: ��--) , <br /> Phase II Grout Inspection h se III Final Inspection <br /> Inspection 8y Date �� Ins a tion By� ate �} <br /> IL71 3 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ' ❑ PER SITE EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Jury 31 <br /> BILLING __ REMITTANCE $ REMIT <br /> w BASE EXPLANATION.— AMOUNT DUE y CHECKED <br /> DATE'S ~'" DATE'— "�' REMITTED" AMOUNT <br /> FEE I <br /> v <br /> LESS <br /> PRORATIONa 1 <br /> PLUS t <br /> PENALTY t <br /> OTHER M <br /> OTHER r• <br /> Received by Date - Receipt No. Permit No. ice Date Mailed — " "Delivered s. r <br /> APPLICANT—RETURN ALL COPIES Tp: - ENVIRONMENTAL HEALTH PERMITISERVICES _ - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9$201 _ '� <br />