Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION t <br /> (For Non-Transferable, Revocable, Suspendable) w + <br /> ENVIRONMENTAL HEALTH PERMIT J PUMP&WELL <br /> I <br /> jCOMPLE'F_ 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._Th_is application is <br /> —� - - -— ' <br /> made in complianc,edv,with-San Joaq n County Ordinance No:'1862 and th rui olid-regulations of the Sa 'J aquln LcafHealt District. <br /> Exact Site ddress�l�L6Z��.'L]�C-7�.5�.�"'a���� �°7F/ City/Town <br /> Owner's Name f�tlPhone �13� , 9Q <br /> Address City 11!a f� �V <br /> Contractor's Name License# n2WM3 Business Phone <br /> Contractor's Address Emergency Phone 1636__4;;)_'7/' t <br /> Is Certificate of Workman's Compensation n ranee.on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ ELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ '0 <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy I <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 ❑ CABLE TOOL Dia. of Well Excavation <br /> )4DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing .iPvG <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 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 /> 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 /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, 1 shall employ persons subject to workman's compensation laws of California." <br /> I will II fora Grout Inspecti prior to groulin and a final inspection. + <br /> I <br /> Signed X Title: Date: I <br /> (Draw t Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date <br /> Additional Comments: <br /> / se I rout Inspection Phase III inal Inspection <br /> Inspection By i� ' <br /> % Date � Inspection By Date r <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BiLtING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKfT <br /> AMOUNT <br /> FEE x <br /> ' LESS <br /> PRORATION ; <br /> PLUS <br /> PENALTY <br /> OTHER 1 <br /> OTHER <br /> � 'Q ' <br /> !1 <br /> Received by LDaIeV Receipt No. Permit No. Issuance 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 />