Laserfiche WebLink
rApplications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE)'I.§a( W. FFr ACL,,, 12:7WATER QUALITY <br /> cD 25 —off—O v <br /> Appl icat ion 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 Joa i ounty Ordinance No. 18 and the rul s and re lations of the San oaq ill Local Health District. <br /> Exact Site Address ity/Town p /� <br /> Owner's Name Phone fi ! 3Y'q, <br /> Address _ t'-- City <br /> Contractor's Name License#� �� Business Phone d <br />" Contractor's Address Emergency Phone rl <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No (yam <br /> TYPE OF WORK (CHECK): NEW WELL 11DEEPEN 11RECONDITION El DESTRUCTION❑ u l <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well s <br /> INTENDED USE 1 TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC 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 /> ❑ GEOPHYSICAL Surfa a Seal Installed By: <br /> PUMP INSTALLATION: Contractor -�� <br /> Y <br /> Type of Pump <br /> H.P. , <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth ;. <br /> Describe Material and Procedure [ sr <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 <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call fpr a Grout Inspection prior to grouting and a final inspection. <br /> a <br /> Signed XTitle: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> t <br /> FOR DEPARTMENT USE ONLY q <br /> PHASE I ` }—4-Application Accepted By ` Date —1 i- <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phas III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee IS Due: 1-1ANNUALLY ElPER UNIT ❑ PER SITE ElEACH Ely ❑January 1&Received By Januar 3 ] <br /> July 1 &Received By July 31 <br /> BILLING REMITTANCE REMIT I <br /> - BASE EXPLANATION <br /> DATE DATE REMITTED AMOUNT DUE CHECKEDAMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> k <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> T5_ <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9$201 <br />