Laserfiche WebLink
*Mw-- Applications Will Be°Processed When Submitted Properly Completed. Be SureToSignTheApplication. <br /> FOR OFFICE USE: I APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> 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 /> made in compliance wi n,�oaqu County Or nce No. 1B 2 e Ovules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address City/Town <br /> �r <br /> I Owner's Name Phone <br /> ' Address City <br /> k <br /> Contractor's Name I� License 422—A-11:2— Business Pine <br /> Ob <br /> Contractor's Address Emergency Phone r <br /> Is Certificate of Workman's Compensatior�I s rance on File With SJLHD? . Yes_�� No. <br /> TYPE OF WORK (CHECK): NEW WELLDEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION 11 WELL ABrANDONMENTO OTHER I , PU INSTALLATeION O I IJP P REPAIR❑ <br /> F REPLACEMENT❑ tl / <br /> i <br /> DISTANCE TO NEAREST: Septic Tank Sewer Line 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 I ❑ CABLE TOOL Dia. of Well Excavation <br /> 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 I ❑ OTHER Other Information <br /> I ❑ GEOPHYSICAL Surface Seal Installed By:_ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. (K <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well DiameterApRivimaA Depth <br /> C I 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 ruffles and regulations of the San Joaquin Local Health District. <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 taws 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 shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspectilo prior t grouting and a final inspect' <br /> i, <br /> Signed X Title: Date: 7 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I IN <br /> Application Accepted ByDatee!, <br /> Additional Comments: IM <br /> Phase 11 Grout Inspection Be III Final I ection <br /> 1 Inspection By ill. Date Inspection By — ate ,JO"��-6 <br /> I. I <br /> Fee Is Due: 13 ANNUALLY El PER UNIT El PER SITE ❑ EACH ❑ January 1 &Received By January 31 July 1 R Reci'ived By July 31 <br /> iiREMIT <br /> BASE I� EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE O Ip <br /> LESS III <br /> ' PRORATION I - <br /> PWS yp <br /> PENALTY ,y <br /> OTHER I� <br /> OTHER <br /> Received by Date Receipt No. P rmit No- Iss ante D,te Mailed Delivered <br /> I <br /> -.APPLICANT—RETURN ALL COPIES TO: I ENVIRONMENTAL'HEA LTH PERMIT/SERVICES � 1601 E.HAZELTON AVE.,P.O.Sox 2009 STOCKTON,CA 95201 <br />