Laserfiche WebLink
r.Nt7 nt:mwna rr.0 ne r.ua:caamv rr.cn uuaan.aac.. r.v}ac .� v.i,..f..a.c.... ...c v...c ... ...y.. ..,.. .-.r.F•,••••••••••,• <br /> FOR OFFICE USE: APPLICATION <br /> ` J(Fo►Non-Transferable, Revocable,Su <br /> spendable <br /> PUMP &WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) <br /> WATER QUALITY <br /> T Application is hereby madeto the San Joaquin Local Health District for a permitto construct and/or install the work herein described.This application is <br /> { made in compliance with San Joaquin ounty Ordin ce No. 1862 an a rules and regulations of the San Joaquin Local Health District. <br /> f + Exact Site Address . City/Town <br /> Owner's Name r- Phone r 1_— <br /> Address City r <br /> Contractor's NamenAl License# Business Phone <br /> Contractor's Address _ Emergency Phone <br /> Is Certificate of Workman's Compensation Insur ce on Fil ith SJLHD? Yes No v i <br /> �! TYPE OF WORK (CHECK): NEW WELL DEEPEN RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDON NT ❑ OTHER ❑ a <br /> P INSTALLATION 11 PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> I Sewage Disposal Field Cesspool/Seepage Pit Other ; <br /> 1 <br /> I Property Line Private Domestic Well Public Domestic Well <br /> �^ INTENDED USET,(AE OF WELL �� / <br /> ' 1 t ❑ IN TRIAL WCABLE TOOL pia. of Well Excavation_! !O �� <br /> Y� DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing _ X.2 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> a ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal —= <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout 4 - . <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> I PUMP INSTALLATION: Contractor <br /> '2 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 /> FI hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> t � <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 /> C1 <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 <br /> permit is issued, I shall employ per ons subject to workman's compensation laws of California." <br /> f-- I will c or a Grout Inspect1 or t grouting and a final inspec ' <br /> Signed X Title: _ �L�'�Y Date: - <br /> (Drawof Plan on Reverse Side) <br /> IIfOR DEPARTMENT USE ONLY <br /> 1!`s <br /> PHASE [ <br /> Application Accepted By _ _. Date <br /> Additional Comments: <br /> + h II Grout Inspection Ptoze lirfinal Inspection <br /> Inspection B❑ y atg Inspection By Dat <br /> Fee Is Due: ANNUALLY PER UNIT �❑ PER SITE ❑ EACH ❑ January 1 ` eived by January 31 ❑ &Received By July 31 <br /> r� REMIT <br /> BILLING REMITTANC $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> j FEE tD <br /> LESS <br /> PRORATION <br /> i� PENALTY <br /> r ti OTHER �k <br /> l OTHER J - <br /> M1 Received by Date Receipt No. Permit No. I suanc pate Maifed Delivered <br /> 42i APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AYE.,P.O.Box 20D9 STOCKTON,CA 95201' <br />