Laserfiche WebLink
Applications Will Be Processed When Submitted ProperlyCompleted. BeSure tosign IneKppncazru <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&/ r FELL <br /> s <br /> ENVIRONMENTAL HEALTH PERMIT <br /> �l70�E�D�- 1a WATER QUALITY <br /> (COMPLETE IN I-RIPLICATE <br /> ApplicatOn iinnereby made to the San Joaquin Local Health District for a permit to construct an <br /> install the work herein described.This applicatiF�n is <br /> made in compliance with San Joaquin County Ordinance o. 6 and the rules and regulations of the San Joaquin Local Health District. <br /> ., City/Town 4 <br /> Exact Site Address <br /> Phone <br /> Owner's Name I <br /> City <br /> Address <br /> Contractor's Name License# a Business Phone <br /> Contractor's'Admess 011 mergency Phone '� 7 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> __ <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ If 0 <br /> DISTANCE TO NEAREST: Septic Tank_ AO� Sewer Lines Pit Privy <br /> Sewage Disposal Field 01 Ce Pit Other <br /> t Public Domestic Well <br /> Property Line Private Domestic Well {- <br /> t INTENDED USE TYPE OF WELL <br /> ff <br /> 11 INDUSTRIAL <br /> C1 CABLE TOOL Dia. of Well Excavation / A,pr <br /> r DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing + <br /> DRIVEN i <br /> ❑ DOMESTIC/PUBLIC ❑ Gauge of Casing <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> 11 DISPOSAL <br /> ❑ OTHER Other Information 6 "� <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> F PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> I PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> ! DESTRUCTION OF WELL: <br /> Well Diameter Approximate Depth <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 <br /> ordinances, state laws, and rules and regulations of the,San Joaquin Local Health District. <br /> t Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich this permit <br /> C is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> . z <br /> Contractor's hiring or sub-contracting signature certifies the following:"l 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 will all for a Grout Inspec• n prior to groutingand a final inspection. <br /> 1 � Title: � Date: <br /> Signed X <br /> (Dr Pict.Plan on Reverse Side) <br /> k FOR DEPARTMENT USE ONLY r <br /> PHASE I11 .�w Date I <br /> Application Accepted By "'����iiCCC <br /> Additional Comments: <br /> , Phase HI Final Inspection <br /> Qh a II ut Inspection <br /> I. Date Inspection 6y �✓ Date <br /> Inspection By <br /> d By <br /> 4 Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ElEACH 0 January 1 &Received By January 31 ❑ July 1 8 Receive <br /> REMITuIy 31 <br /> ON BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> EICPLANATi <br /> BASE DATE DATE REMITTED AMOUNT <br /> ' FEE .k— <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> r�1 1 -?oaa �R <br /> ate Receipt No. Permit No. 4ssuan a Date Mailed Delivered <br /> Received by <br /> 1fi01 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9520 <br /> APPLICANT—RETURN ALL COPIES TO; ENVIRONMENTAL HEALTH PERMIT <br /> lSERYICES _ <br />