Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Tp Sign The Application. I IJ <br /> FOR OFFICE USE: APPLICATIONp <br /> (For Non-Transterable, Revocable, Suspendable) APR 3 1900 <br /> PUMP&WELL <br /> Ir} ENVIRONMENTAL HEALTH PERMIT SAN JOAQUIN LOCAL <br /> (COMPLETE IN TRIPLICATE) 6 $ is IvATER QU ITHEALTH DISTRICT <br /> , <br /> Application ishereby made tothe San Joaquin cal Health Districtf rap6FA oc nsructand/or install thework herein described.This application is <br /> made in complia with San Joaquin Count Ordinance 1862 and the rules and regulations of the Sa Joaquin Local Health Istrict. <br /> Exact Site Address� `� City/Town r- j� <br /> Owner's Name _ t c� Phone _7�z -7- r r <br /> Address ' City ( ; — l <br /> Contractor's Name Licensed <br /> #i/2� � �"� Business Phone � y 5' - ( ��/ <br /> Contractor's Addresrs i—4 Emergency Phone <br /> Is Certificate of Workman's Compensation Insura ce on f=ile With SJLHD? Yes AC.-- No -�- <br /> TYPE OF WORK (CHECK): NEW WELLDEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank M, --,>"r . Sewer Lines /11)n. f; l Pit Privy ; <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Z C�o Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑�, INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ��-- <br /> L r VOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing Z ` <br /> 0-TTMIGATION �RVEL PACK Depth of Grout SealZ.� <br /> ❑ CATHODIC PROTECTION D-M!TARY Type of Grout % <br /> ❑ DISPOSAL ❑ OTHER Other Information 5 <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: 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 Approximate Depth <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 /> 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-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 call for a Grout Inspection prior to grouting and a final inspection. C j <br /> Signed XQik�-� �� Title: �� 1--ti..�.7�r� Date: <br /> (Draw Plot Plan on Reverse Side) <br /> �I <br /> FOR EPART ENT USE ONLY ' <br /> PHASE Ea <br /> Application Accepted By - �'�""'� U Date <br /> Additional Comments: <br /> P II Gro Inspection /P e I Final 1 ection <br /> Inspection By Date j Inspection By ►�+ to ! <br /> t <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 July 1 &Received By July 31 <br /> BILLING REMITTANCE g REMIT s <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit NoIssua ce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />