Laserfiche WebLink
d c t1�h Wi11 Be Proces ed VPhen submitted Property.Compieted.Be Sure To Sign The Application. 1�1 <br /> 1 APPLICATION <br /> FOR OFFICE USE: c] �y ` I� <br /> IY,n-Transferable,Revocable,Suspendabte) f� PUMP&WELL <br /> RONMENTA"EALTH PERMIT <br /> ' COPY <br /> (PLICATE R' Dj� WATER gUALIT�. <br /> {COMPLETE IN TR P R __� <br /> 1 tri taIlTfle or herein described.This application is <br /> AppiicationisherebymadetotheaVJoaquinLocalHealthDistrictforapermittoconstructand/or s <br /> made in compliance with San Joaquin Cou y O 'nance No. 18�nd le rules and regulations of the San JoaquinLocal I Health istrict. <br /> Exact Site Address 7 6-32-6� ' Ut - City/Town <br /> ` <br /> Owner's Name l- ' t �Y &Dk 6,4Z TA ' � Phone (7 SCJ �� Z. <br /> Address i"'i� CityJESCr - <br /> - <br /> +' Contractor's Name s.: v� License#���L-3/ _ Business Phone /` 'S,IT��� )'�' <br /> 1 Contractor's Address o03 J91r° Emergency Phon rr►rC� , <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD7 Yes—/iL No N <br /> TYPE OF WORK(CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ <br /> REPLACEMENT <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property.Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ' ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Weil Excavation <br /> I 19 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC. ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done .e <br /> PUMP REPAIR: ❑ State Work Done <br /> t DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 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." <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 it emp oy persons subject to workman's compensation I ws of California." <br /> I wi It f a Gr Lit ns" tion prior to grouting and a final Inspec <br /> k Signed X <br /> Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I GL <br /> NIX <br /> i Application Accepted By cX Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection h se I Final Inspection <br /> I`r[ Inspection-By—td\ C1Date Inspection By Date — <br /> f LY ❑'PER UNIT ❑ PER SITE ❑ EACH nuary❑ Ja1 &Received By January 31 ` 0"d uly 1 &Received By July 31 <br /> 'r Fel'Is Due: ❑ ANNUAL REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> F DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> r PENALTY <br /> OTHER <br /> OTHER <br /> 3 <br /> Received by Dat4 Receipt No. Perrrfit No. Issuance Date Mailed- Delivered <br /> APPLICANT-'RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P.O.Bos 2009 STOCKTON,CA 95201 <br />