Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transierable, Revocable, Suspendable) <br /> PUMP&WELL <br /> "t 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 isA <br /> made in compliance with San'Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. / <br /> Exact Site Address D (0 1 . 1� S� City/Town L f <br /> Owner's Name Phones <br /> AddressAITrM 1.f t�1(�. City tn Qom ` <br /> Contractor's Name HE-01.?1ob-'i 13rz0S I'I Business Phone <br /> Contractor's Address• 2Z ?VUN >h. u NQ C Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No O� <br /> TYPE OF WORK (CHECK): NEW WELL® DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ O <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ � <br /> DISTANCE TO NEAREST: Septic Tank /00--1- Sewer tines Pit Privy <br /> Sewage Disposal Field /00.* 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 /> I� DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing x <br /> ❑ <br /> ❑ DRIVEN Gau a of Casing X1114 DOMESTIC/PUBLIC 9 <br /> ❑ IRRIGATION ® GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION I) ROTARY Type of Grout I ePAL^x1 is 4 <br /> ❑ OTHER Other Information SLA1� \3\ t�zSZt_D <br /> 11 DISPOSAL <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. [f� <br /> PUMP REPLACEMENT: ❑ State Work Done r <br /> PUMP REPAIR: 0 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 :f <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 i <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed XTitle: k, � Date: ; <br /> (Draw-Plot on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI / <br /> \F <br /> Application Accepted By <br /> �fZl ` -� — Date <br /> Additional Comments: <br /> d <br /> Phasl*Grout Inspection 1 Phas Inspection <br /> ,, /A/ I�AI Inspection B Date <br /> Inspection By -'—`�� Date p Y <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 J <br /> REMIT 1 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS r ` <br /> PRORATION a <br /> PLUS r <br /> PENALTY ^D <br /> OTHER <br /> OTHER <br /> /� B d7 (cvo <br /> Received by Date Receipt No. Permit No, Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952 1 <br />