Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> -FOR OrFICE USE: APPLICATION <br /> J ��,For Non-Transferable, Revocable,Su3pendable4 PUMP&WELL <br /> -- LoMp ° o� ENVIRONMENTAL HEALTH PERMIT <br /> COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> nade in compliance with San Joaquin County 0 finance No. 1862 and the rules and rvpaulations of the San Joaquin 1-9cal Healt�istrict. <br /> =xact Site Address a Pyy k<��'S°"�� " � �� �" ^''� r,4 A-�3otiCity/Towf1 SGrp oIF <br /> iip <br /> Dwner's Name a C Phone <br /> Address C ✓ ..�e u ` !C Yrh f t <br /> contractor's Name License#173 7 yBusiness Phone SSG i — �� �"� Q <br /> contractor's Address s Emergency Phone <br /> is Certificate of Workman's Compensation In rance on File ith SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> NELL 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 Well Excavation N <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 91 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal N <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout p <br /> ❑ DISPOSAL ❑ OTHER Other Information �• <br /> ❑ GEOPHYSICAL �f/ Surface Seal In Called By: <br /> PUMP INSTALLATION: Contractor�7 61 �' v`, F_4D -- £ <br /> Type of Pump -��✓ H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done -t <br /> PUMP REPAIR: M State Work Done �c� i+ ,r[fJ l'� mss' � <br /> DESTRUCTION OF WELL: Well Diameter rr- Approximate Depth y <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 y <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 C <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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California.' <br /> 1 wKI call for a Grout Ins n 'or uting and a final inspection. <br /> Signed <br /> Title: .!Ap r, Date: LZ <br /> (Draw PIM Plan on Reverse Side) <br /> OR D PARTME T USE ONLY <br /> PHASEI <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date 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 $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS 3 C U <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> col ��� <br /> Received by Date Receipt No. Permit No Issuan a Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />