Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable;Suspendable) PUMP&WELL <br /> fJ ENVIRONMENTAL HEALTH PER IT <br /> f�� WATER QUALITY,.. fY!!� .-,/ j►� <br /> (COMPLETE iN TR}Pl KATE) - - � ,L <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install thew ork. ereln escri ed.This application is <br /> made in compliance with Sanoaq uin C nt Ordinance No. 18 2 and t rulesan regulations of the,San.J aquin gcal Health District. <br /> Exact Site Address w+` R O 1- City/Town <br /> I - - Phone , <br /> Owner's Name <br /> Address �_ S. :[• J ,- .. City <br /> Contractor's Name 'r t License#s 77 Busi eSS Phone <br /> Contractor's Address ..`Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_ — No y{1 <br /> TYPE OF WORK (CHECK): ANEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ _ Od <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 13 OTHER ❑ PUMP INSTALLATION 11 PUMP REPAIR❑ <br /> REPLACEMENT❑ k 1F C <br /> DISTANCE TO NEAREST: Septic Tank 0 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 +t <br /> ❑ INDUSTRIAL_ h❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE #❑ DRILLED Dia. of Well Casing <br /> ❑ Gaof Casing a <br /> ❑ DOMESTIC/PUBLIC' DRIVEN uge Q <br /> ❑ IRRIGATION t i] 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 t <br /> Type of Pump H.P. <br /> I ❑ State Work Done <br /> PUMP REPLACEMENT: - <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> y t 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 _ h <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Q� <br /> Contractor's hiring or sub-coritractil signature certifies the following:"I certify that in the performance of the work forwhich this <br /> i permit-is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 71,�Ioa rout Inspects n prio grouts �Pan <br /> final inspection. <br /> Signed X Title: Dale: <br /> (Dralon Reverse Side) - <br /> t <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application.Accepted By Art Date <br /> Additional Comments: _ <br /> s IY rout Inspection �� �.e III Final Inspectionrr <br /> Inspection By Date At Inspection By Date t� <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 <br /> PRORATION - <br /> PLUS N r <br /> PENALTY <br /> t <br /> OTHER J <br /> OTHER <br /> r <br /> Received by - - <br /> Date s Receipt ND Permit No. ssuanc D e Mailed . t Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOC_KTON,CA 95201 <br />