Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> k FOR OFFICE USE: }r3 O9- APPLICATION j, <br /> (For Non-Transferable, Revocable, 5uspendable) <br /> 1PUMP&WELL <br /> fire- ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) k WATER QUALITY 896 W '(4RIN�t <br /> Application is hereby made to the San Joaquin Local Health District for apermittotand/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the ruleco and regulations of the San Joaquin Local Health District. <br /> Exact Site Address E14"I' 64SF 'DA•V!S r-D o'-Sld'_g4 UAMR—w City/Town L oDI <br /> Owner's N _ Phone <br /> Address E— U City <br /> r Contractor's Name License#337orPT�-Business Phone 7 —3 37 <br /> Contractor's Address 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 ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 13 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 7 Sewer Lines -7 Pit Privy t a <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> 1 <br /> Property Line= Private Domestic,Well.—J -—Public Domestic Well <br /> _ - P Y �n <br /> INTENDED..USE---.-. - --:7TY0EOFWELL,,-_ - <br /> ( ❑ INDUSTRiAL - - - -- - -- ----•�K CABL-E-T_OOL Dia:-of Well•Excavation <br /> DOMESTIC/PRIVATE 4 DRILLED '= i Dia:of Well-Casing ;-, '= ' <br /> _. <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION - ❑ GRAVEL PACK Depth of Grout Seal 5—d <br /> ❑ CATHODIC PROTECTION, J❑.:ROTARY Type of Grout <br /> 11DISPOSAL ❑ OTHER i Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <g1_457, t/ A(Ag L VelCZ/ <br /> r PUMP INSTALLATION: Contractor ;+ TM ! <br /> t Type of Pump' H.P, <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 4.11 State Work Done I <br /> DESTRUCTION OF WELL: Well Diameter ) Approximate Depth <br /> I ` �117escribe Material and Procedure <br /> I <br /> : <br /> i <br /> I I"I' hereby certify that I have prepared this application'arid 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 /> I Home owner or licensed agent's signature certifies the following!:"I certify that in the performance of thework forwhich 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." 1y <br /> f%(Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> s , <br /> s I will II for a Grout Inspection riot o_grouting_and a final_irispecttiio�n,. ; <br /> Signed X'� Title: Date: 7 ® <br /> I ? (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 <br /> Application Accepted By. Date <br /> Additional Comments: <br /> Phase 11 Gr ut Inspection tov- <br /> I Inspection •pp��-� <br /> i Inspection By Date k— tov-An Inspection By Date <br /> t <br /> L 5 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Re ived By January 31 . ❑ July 1 &Received Sy Jufy 31 <br /> I BILLING REMITTANCE $ REMIT i <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> } LESS <br /> �:• PRORATION - <br /> PLUS F <br /> PENALTY • <br /> OTHER <br /> t: <br /> OTHER <br /> P1/ <br /> Received by Date -$ Receipt No,, Permit No. Issu nc a Mailed Deli ered <br /> APPLICANT—RETURN ALL COPIES TO:E} ENVIRONMENTAL HEALTH PERMIT/SERVICES - - `1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 85201 <br />