Laserfiche WebLink
f Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION ' <br /> 2 .30 (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WEI_I- <br /> COMPLETE IN TRIPLICATE _ ATER QUALITY <br /> Application is hereby made tot eSanJo quin oca Healt� rica <br /> r permit to construct and/or install the work herein described.This application is <br /> made in compliance wiith1 San Joaquin County Ordinance No. 1862 and the rulgs and r gul!�,,of zf�e,SpaS Joaquin Loy�c"al Health District. <br /> Exact Site Address lel � � -J✓ 7 .t�i4.Nl.rut.rJ ��lr�ar.t r Clt%yd`/hToiwn�l/ /��c kt, 2o, <br /> Owner's Nam C-- 2( 6C 6 -K �- Phone `'-�t1&5'—_7-�C-3 <br /> Address 0, # City D rr_9i'ldf. �1 <br /> Contractor's Name License# .3�4 q_5a_Business Phone - 7?7 <br /> Contractor's Address (t—iy' 4 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 /> WELL CHLORINATION 13WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> t 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 -� <br /> I INTENDED USE TYPE OF WELL x r <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ! <br /> DOMESTIC/PRIVATE El DRILLED Dia. of Well Casing f <br /> ❑ DOMESTIC/PUBLIC ❑ RIVEN Gauge of Casing +I �. YX <br /> 11IRRIGATION AVEL PACK Depth of Grout Seal 0 r <br /> 11 CATHODIC PROTECTION ROTARY Type of Grout Y 14 <br /> ❑ DISPOSAL ❑ OTHER Other information <br /> © GEOPHYSICAL Surface Seal Installed By: _- ow"o� <br /> PUMP INSTALLATION: Contractor <br /> _Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> x DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> I Describe Material and Procedure <br /> 1, <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 /> Y <br /> Home owner or licensed agent's signature_ certifies the following:"I certify that in the performance of thework 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 4. <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." i <br /> t ` <br /> 17=c .�.pr a Grout Inspec on prior to grouting and a final inspection. - <br /> Signed X f TIIIe: °S �{ _' _ Date: / <br /> ( raw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> k PHASE &L <br /> t <br /> Application Accepted By bate <br />! Additional Comments: <br /> Phase it.-Groo/ut Inspection / Phase III Final Inspection <br /> f .Inspection By 52 Date (y y�� Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH_ ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31---; • 1 <br /> REMIT <br /> BILLING REMITTANCE $ <br />` BASE CHECKED <br /> EXPLANATION DATE DATE REMITTED AMOUNT DUE AMOUNT <br /> E FEE 8 <br /> II LESS <br /> PRORATION r <br /> PLUS <br /> PENALTY - <br /> ' OTHER <br /> OTHER <br /> -r <br /> Received by Date ' Receipt No. - Permit No. Issuan Date Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ' ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAXELTON AVE.,P.O.Box 2009 STOCKTON,CA 95 <br />