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) 7 PUMP&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 San Joagvtn C unty Or�d}in�,a�ce 1862 and h rules and regulations of the San J uin Local Health District. <br /> Exact Site Address G� P hCf� � City/Town <br /> Owner's Name � Phone <br /> Address City <br /> Contractor's Name License __ Business Business Pho ` 1 <br /> Contractor's Address !�� Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? YeNo <br /> TYPE OF WORK (CHECK): NEW WEL� DEEPEN 11 RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIOX-80 PUMP REPAIR El <br /> REPLACEMENT❑ / <br /> DISTANCE TO NEAREST: Septic Tank -;z 10L1 Sewer Lines C1 Pit Privy <br /> !� Aem/0AI) Sewage Disposat Field, �d r Cesspool/See vge Pit Other <br /> Property Line_,Private Domestic Welles/ Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> W1❑ DUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> OMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing Z, <br /> l <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 0 ver <br /> ❑ IRRIGATION 11,,�GRAVEL PACK Depth of Grout Seal <br /> 11 ,, <br /> CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL §urface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 1H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 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 /> lab <br /> Contractor's hiring OF 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 wi I for a rout 1 pection r to gr ting and a final inspection. <br /> Signed X �f � , Title: ' �_ - Date: <br /> (Draw Plot Plan on Reverse Side) <br /> t FOR DEPARTMENT USE ONLY <br /> PHASE <br /> ti <br /> Application Accepted By Date <br /> Additional Comments: <br /> se rout Inspection �� P se Final Inspection <br /> .y J f w� Y <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUAL ER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE . . O <br /> r <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER �S <br /> OTHER <br /> Received by Date Receipt No. Permit No Is uanc 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 />