Laserfiche WebLink
ppncauonsWill Be Processed When Submitted Properly Completed, 8e �e Tigrt 1111e Application. <br /> OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable J�N ` Q 1981 <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> k (COMPLETE IN TRIPLICATE) WATER QUALITY SAN J0.;!1Q1,11N LOCAL <br /> RIC <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the ork herein LTH �escr bed.T his application is <br /> made in compliance with San Joaquin County Ordinance N . 1662 and the rules and regulations of the San Joaquin Lo al Health District. .� <br /> Exact Site Address f` –. <br /> I City/Town c r (o <br /> Owner's Name !! r <br /> Address Phone <br /> Contractor's Name ,t City r <br /> f. `Contractor's Address License# �Z-- Business Phone -�. �,� <br /> +��Z._��' i}'11�-R4Y <br /> Is Certificate of Workman's Compensatio Emergency Phone <br /> jlnsurance on File With SJLHD? <br /> TYPE OF WORK (CHECK): NEW WELL' DEEPEN ❑ Yes No _ <br /> WELL CHLORINATION 11RECONDITION❑ DESTRUCTION❑ <br /> WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank <br /> Sewer Lines Pit Privy <br /> Sewage,Disposal Field, _ f2R Y�— cesspool/Seepage Pit <br /> Other j <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL �# <br /> OMESTIC/PRIVATE Dia. of Well Excavation <br /> 10 ❑ DRILLED Dia. of Well Casing <br /> DOMESTIC/PUBLIC ❑ DRIVEN <br /> C1IRRIGATION �.- Gauge of Casing r <br /> AVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTIONOTARY <br /> ❑ DISPOSAL ormaonType of Grout <br /> id <br /> 13 GEOPHYSICAL <br /> ❑ OTHER Other Infti <br /> PUMP INSTALLATION: # Surface Seal Installed By: <br /> Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> % Approximate Depth r <br /> Describe 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 /> Home owner 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 orsub-contracting signature certifies the following:"I 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 cam for a Grout Insp ction prior to grouting and a final inspection, <br /> Signed X <br /> � Title: <br /> 61 <br /> ' Date: . <br /> raw-Plot'Pfan on•Reverse Side) - <br /> 1 <br /> PHASE FOR DEPARTMENT USE ONLY 4 <br /> Application Accepted By rL i <br /> Additional Comments: Date b t <br /> Phe out Inspection <br /> Inspection By �( � �� Phase IIlf�naDate Inspection <br /> � _ /Y�Iy• <br /> Fee IS Due: ❑ Date Inspection By ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCEREMIT -- <br /> DATE" .DATE REMITTED AMOUNT DUE CHECKED <br /> FEE `� _ AMOUNT <br /> LESS <br /> PRORATION - <br /> PLUS !! <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date . yi'' <br /> Receipt No Permit No. Issu nce D e f <br /> - - "APPLICANT—RETURN ALL COPIES S TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES Mailed .Delivered - ,r <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 <br /> .-. b SIDCi(TON-ce nsgna 4 <br />