Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR_O'�%FICE USE: '-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 Districtfora permit to construct and/or install thework herein described.This application is <br /> made in compliance with San Joaquin Co y Ordiwance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address /a y� AA-se. A;.4 City/Town <br /> AO <br /> Owner's Name f � a Phone <br /> Address City <br /> Contractor's Name License# ee 4°9 9=J Business Phoneme <br /> Contractor's Address Emergency Phone 7 - <br /> Is Certificate.of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIOWt5- PUMP REPAIR❑ I <br /> REPLACEMENT❑ (" <br /> DISTANCE TO NEAREST:. Septic Tank Sewer Lines . � Pit Privy - . <br /> ����/� Sewage Disposal Field Cesspool/Seepage Pit Other <br /> !/ �" e"_D.r Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL ' t ell <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> if <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing —1?�74--g-vi <br /> ❑ IRRIGATION ��,RAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Si face Seal Installed By: 'PC16�A=4 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump A t~ z H.P. O <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done tar <br /> DESTRUCTION OF WELL: Well Diameter a Approximate.Depth <br /> Describe Material and Procedure r� <br /> r <br /> I hereby certify that I have prepared phi application and that the work will be done in ac `dance with San Joaquin County <br /> ordinances, state laws, and rules 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 laws 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 or a Grout Inspection prior to groutin=itle: <br /> al inspection. <br /> oe <br /> Signed X Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ` $� <br /> Application Accepted By !f Date <br /> Additional Comments: <br /> Ph a Grout Inspection L� r Pa 11 II Final Inspection <br /> Inspection By '� Date 6Jl Inspection By .���'"' ^' Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January I &`Received By January 31 ❑ Juiy 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by D to Receipt No, Permit No. Iss ante D to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 <br />