Laserfiche WebLink
Applications Will Be Processed When SubmittedProperlyCompleted sesure 1o sign Iner%ppimanvn. <br /> FOR OFFICE USE: ,y�, APPLICATION l <br /> (For Non-Transierable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> I Application is hereby madetotheSan Joaquin Local Health District fora permitto constructand/or install thework herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and reguljtions of the San Joaquin Local Health District. <br /> C / W6alkP .d�+ 411 B fax pr-1e ity/Town <br /> r Exact Site Addresses � <br /> Owner's Name �= i Phone <br /> Address o r ce N A-1 Ja !] City— <br /> Address <br /> } Contractor's Name &. 154i License# /J ?).-�Business Phone 46 L d R Ila 7 <br /> Contractor's Address�6;l V a ZA& ..� AQA' Emergency-Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No Y <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN 11RECONDITION 11 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ® PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer.Lines Pit Privy <br /> k Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> I INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> k ❑ DRILLED Dia. of Well Casing <br /> g <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ 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 _ <br /> Type of Pump p H.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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> I 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 performanceof 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 /> t <br /> glall l cfor a Grout Ins on rior o g uti�ig and a final inspection. <br /> Signed X + - Title: i Date: <br /> (Draw Plo Plan on Reverse Side) <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By - Date <br /> Additional Comments: <br /> �. Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 R Received By July 31 <br /> I REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED ' <br /> DATE DATE REMITTED AMOUNT <br /> # FEE <br /> LESS <br /> PRORATION - - -- <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> l -3 C1 <br /> 1 Received by Date Receipt No. Permit No. n.4 Date Mailed Delivered <br /> ' APPLICANT—RETURN ALL COPIES To: ENVIRONMENTAL HEALTH PERM ITISEfiVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />