Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> 'OA OATICE USE_ APPLICATION <br /> (For Non-Transferable,Revocable,Suspendable) <br /> --- — PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> MPLETE IN TRIPLICATE) WATER QUALITY <br /> dication is hereby madetothe San Joaquin Local Health Districtfora permitto construct and/or install the work herein described.This application is <br /> Ie in compliance with San Jo7agru^in Count ,.Qrtli rice o. 18 2 and a-rules and regulations of the San_J,.oain Local H Ith District. <br /> ct Site Address_ �/ //[i £_ G L' City[Town Cy �ls'f�a <br /> yer's Name i���'FY �'G Phone <br /> ress ' City _ <br /> (tractor's Name .� -1 /'%Y License tR Business Phone <br /> (tractor's Address Emergency Phone <br /> ertificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> ,E OF WORK (CHECK): NEW WELL 01" DEEPEN ❑ RECONDITION DESTRUCTION❑ <br /> -L CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> 'LACEMENT❑ <br /> iANCE TO NEAREST: Septic Tank Sewer Lines /*/>9!Q ''t Pit Privy <br /> Sewage Disposal Fleld Casspoei/Seepage Pit _//.1l} "� Other <br /> Property Lina!TL)d Private Domestic Well "` Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> / <br /> NDUSTRtAL ®C BLE TOOL Dia. of Well Excavation f /� <br /> DOMESTIC/PRIVATE U-1pILLED Dia. of Well Casing /� y <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> RRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> :ATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> DISPOSAL ❑ OTHER Other Information <br /> ;EOPHYSICAL Surfacp Seal Install By: �"'/ �— <br /> AP INSTALLATION: Contractor-,.��y!,4 /'/1y12t.6.1A �� r <br /> Type of Pump S's_�,f,f�Y�r H.P._•_ p <br /> AP REPLACEMENT: ❑ State Work Done <br /> AP REPAIR: ❑ State Work Done <br /> iTRUCTION OF WELL: Well Diameter 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 T. <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. SS <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 /> Contractors hiring or subcontracting 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 /> I all for a Grout Inspection prior to grouting and a final inspection. /y <br /> led 1 *Ule,. � �'ti� iData. t <br /> (Draw Plot Plan on Revers id e) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE( a <br /> Application Accepted By A<d Date C°4_2or <br /> Additional Comments: <br /> Phas <br /> 11 out Inspection p 11 Fin apection�j d <br /> Inspection By Date n- p'� Inspection By Date O _ <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT IW PER SITE ❑ EACH ❑ January 1 8 Received By January ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE f AMOUNT DUE CHECKED <br /> DATE DATE REMITTED �+ AMOUNT <br /> FEE - '/�Sir <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER p <br /> OTHER —.— <br /> n ......,a.. rlara QVgnl Nn �Nn leannnna rlab Mai1M ru.,........w <br />