Laserfiche WebLink
f1PPII%;4tIVIIV Iry III oC rIUA;e3*VU WIMP$ODUIIHILMIJ r-IUPt:IIy {..UIIIPICICU. Ott OUIC IU 01911 IIIC}IPIAILallUlt. <br /> FOR OFFirE USE: APPLICATION <br /> .=or Non-Transferable, Revocable,Suspendable) PUMP gt WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> COMPLETE IN TRIPLICATE} WATER QUALITY <br /> application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with S n Jaaquirn ounty OrdinarIce No. 186 and the rules and regulations of the San Joaquin Local Health District. <br /> Fxact Site Address City/Town 5 "T/'ice <br /> )wner's Name 44 Phone <br /> Address City - <br /> ,ontractor's Name License# B siness Phone'��s <br /> contractor's AddressT-oz- — <br /> Emergency Phones <br /> Is Certificate of Workman's Compensation Insura on File With SJLHD? Yes L� No <br /> YPE OF WORK (CHECK): NEW WELL i1Y DEEPEN ❑ RECONDITION 13 DESTRUCTION <br /> NELL CHLORINATION ❑ WELL ABANDONMENT 13OTHER ❑ BUMP INSTALLATION ElPUMP REPAIR❑ <br /> ,3EPLACEMENT❑ , <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Fill <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELLrO r . <br /> INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation <br /> rDOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> '❑ DOMESTIC/PUBLIC 13 DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ C,RAVEL PACK Depth of Grout Seal i <br /> IJCATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> UMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. I <br /> PUMP REPLACEMENT: ❑ Smote Work Done <br /> DUMP REPAIR: State Work Done <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> f 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,' <br /> Contractor's hiring orsub-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 1 call or a Grout Inspection to gr ng and inal inspection. ' <br /> Signed X <br /> FI Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br />! FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Fes/�/ ( �6��°•••-` ! - Date C <br /> Additional Comments: <br /> Phase 11 Grout Inspection _ Phase III Final Inspection <br /> Inspection By f of-k Date 7 7421- Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ <br /> AMOUNT DUE CHECKED <br /> Fi� <br /> 22 DATE DATE REMITTED AMOUNT <br /> 141-A3 <br /> [ � ~ <br /> FEE 4r� - <br /> LESS <br /> FI. PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> i <br /> k OTHER <br /> I , Received by Date Receipt No, Permit No, l uance bale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> I <br />