Laserfiche WebLink
r Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION `7 7 <br /> (For Non-Transferable, Revocable,Suspendable) <br /> 7 ENVIRONMENTAL HEALTH PERMIT PUMP&WELL ' <br /> � I <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> ti Application is hereby made tothe San Joaquin Local Health District fora permit to construct and/or installtheworli herein described.This application is <br /> l <br /> made in compliance with San Joaquin County Ordinance No.1862 and the rules and regulations of the San Joaquin Local Health District. i <br /> Exact Site Address City/Town I��'/� te.&Ie2 1 <br /> Owner's Name Phone <br /> Address _ i City_4,.i <br /> Contractor's Name Meeff S"A74 .ncc License # 265 7fc/ Business Phone <br /> Contractor's Address ove, A�Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance File With SJLHD? Yes Z__ No J. <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ ' <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT&— <br /> DISTANCE TO NEAREST: Septic Tank Irv" Sewer Lines 1,wPit Privy <br /> Sewage Disposal Fie)d «f Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Idl /' Public Domestic Well <br /> INTENDED USE TYPE OF WELL i <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation e <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing r <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> Z�111RIGATION ❑ GRAVEL PACK Depth of Grout Seal 1 �I <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor VAvf ov{R PN ePses l <br /> Type of Pump p <br /> PUMP REPLACEMENT: ❑ State Work Done C a. 3� . <br /> PUMP REPAIR: ElState Work Done w <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure i. <br /> I� .Y <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 taws, 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 forwhich this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compelnsation 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, I shall employ persons subject to workman's compensation laws of California." <br /> ' 1;=for a Grout Insp ction prior to grouting and a final inspect, <br /> Signed X Title: Date: ?� <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEP RTMENT USE ONLY 1 <br /> PHASEI i <br /> Application Accepted By DateG 7 <br /> Additional Comments: -27 <br /> Phase 11 Grout Inspection Phase Ili Final inspection <br /> Inspection By Date Inspection By Date <br /> Fee I9 Dile: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REM#T <br /> BILLING REMITTANCE AMOUNT DUE CHECKED <br /> - BASE EXPLANATION PATE DATE REMITTED <br /> AMOUNT <br /> FEE ' s d, •} <br /> LESS f r <br /> PRORATION f <br /> PLUS <br /> PENALTY <br /> OTHER <br /> } <br /> OTHER <br /> 9- 57 . 7-At-19 ! Li <br /> Received by - Date Receipt No, •-Permit No. - Issuance Date I ME led Deliveeed J, r <br /> ' I <br /> APPLICANT—RETURN ALL^COPIES TO: ENVIRONMENTAL HEALTH,PERMITlSERVICES 1641 E,HAZELTON AVE.,P.O.Bax 2009 STOCKTON,4A 95201 <br />