Laserfiche WebLink
_ Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR C01FICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <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 with San Joaquin County Ordinance No. 1862 and the rules and regulations of the Sarl,4oaqui Local Health District. <br /> "� <br /> Exact Site Address City/Town c ?�.41 <br /> Owner's Name ' Phone �� j <br /> Address City . { 16r' U, <br /> r .-- <br /> Contractor's Name / y 0 ,��• . License#_� Business Phone� G:%��_ _ ' <br /> Contractor's Address U MEmergency Phone n <br /> Y <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 4t— No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <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 Qe, 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 /> ❑ 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 Informations <br /> ❑ GEOPHYSICAL Surface Seal Installed By: _ NQ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. h <br /> PUMP REPLACEMENT: State Work Done jQ62 1 x. .... 7 / f r .4j.ev <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Dacribe 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, 1 shall employ persons subject to workman's compensation laws of California." <br /> 1 wit call fora grout I ection prior to grouting and a final inspe}tjl�n. <br /> Signed X Title: 1, Date: 1: <br /> (Draw Plot Plan on Reverse Side) <br /> a <br /> FOR DEP TMENT USE ONLY <br /> PHASEI 1 } <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase 111 Final Inspection <br /> Inspection By Date Inspection By _ Date <br /> r <br /> •Fee IS Due: ❑ ANNUALLY 0-PER�UNIT—❑ PER SITE-.- JQ-FAGH ❑ January I &Received By January 31' ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE. EXPLANATION W „+. BILLING,,, _ REMITTANCE $ AMOUNT DUE CHECKED <br /> 'DATE DATE REMITTED AMOUNT <br /> FEE S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER Q•� <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 95201 <br />