Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) lkS0.rL1::f`f, fo�ts�5a:�1= ATER QUALITY <br /> AATER <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein describes).This application is <br /> made in compliance wlt ,Sa��y/Joaquin}County Ordinance No. 186 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address - �� City/Town <br /> Owner's9;Jame Phone <br /> Addrese>./ /:��`$ lie./ �. E rt es City rt / lI <br /> Contractor's Nam Licehse#/ Business Phone <br /> I <br /> Contractor's Address ` Emergency Phone ` <br /> Is Certificate of Workman's Compensation Insurance on File With ILHD? Yes No <br /> TYPE OI'WORK (CHECK): NEW WELLt DEEPEN El RECONDITION 0 DESTRUCTION© <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ -PUMP INSTALLATION ❑ PUMP REPAIRS ) <br /> REPLACEMENT❑ W ' <br /> DISTANCE TO NEAREST: Septic(Tank Sewer Lines 2 Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Welles Public Domestic Well ` <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL a 0 CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE j ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC !; 0 DRIVEN Gauge of Casing a <br /> 9 IRRIGATION © GRAVEL PACK Depth of Grout Seal <br /> I] CATHODIC PROTECTION a� ❑ ROTARY Type of Grout <br /> 0 DISPOSAL t ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL- �l Surface Seal installed By: (') <br /> PUMP INSTALLATION: Contractor / JAr <br /> Type of Pump H.P. �.Al <br /> PUMP REPLACEMENT: ! 0 State Work Done <br /> PUMP REPAIR: ' I ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> ' I hereby certify that I have prepared this application and that the work will be gone in acco_rdance with San Joaquin County <br /> I ordinances, state laws, antl rules and regulations of the San Joaquin Local Health District. C� <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." i <br /> Contractor's hiring or sub 6ritracting signature certifies the following-.Yl certify that in the performance of the work fo+rwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California"'' " <br /> I ill call for a Grout Inspection for gro g-gnd a final inspection. <br /> _ <br /> I <br /> Signed Itle: - Date: rZA <br /> (Draw Plo Plan on Reverse Side) t <br /> ! � FOR DEPARTMENT USE ONLY " <br /> PHASE <br /> 4 <br /> Application Accepted B Date <br /> Additional Comments: 'I <br /> Phase Il Grout Inspection ' fiasy I Final Inspection <br /> Inspection By Date Inspection By r Date 7-- <br /> Fee <br /> Fee Is'Due: ❑'ANNUALLY 13 PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July'1 &Received By July 31 4 <br /> ' REMIT <br /> BASE EXPLANATION EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> !' BDATE DATE REMITTED AMOUNT <br /> 4 <br /> FEE k <br /> LESS <br /> PRORATION <br /> PLUS _ - q - .,.•_ _ - _ <br /> PENALTY <br /> OTHER .. <br /> ..t <br /> r <br /> OTHER <br /> Received by Date :N Receipt No. Permit No. --- Issuhtice Date Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.°Box 2009 STOCKTON,GA 95201 <br /> Ll <br />