Laserfiche WebLink
i UtV1N tk W ELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (CO PLETE IN TRIPLICATE) WATER QUALITY <br />--W-ppplicatiorf i Fiereb�madototheSain-jofi in—ocatf VttYDistrictforapermitto-constructand/or install the work herein described.This application is <br /> made in compliance with$an Juaqui unty Ordinance No. 1862 and the rules and regulations of the Sala.Joaqwn Local Health District. <br /> Exact Site Address — - City/Town -- - <br /> Owner's Name Phone -- <br /> Address e _ city, <br /> �t _ <br /> Contractor's Name License# Business P one <br /> Contractor's Address Emergency Phone —T <br /> c <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 INSTALLATION❑ PUMP REPAIR❑ N, <br /> REPLACEMENT <br /> DISTANCE TO NEAREST: Septic Tank __ Sewer Lines Pit Privy <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 /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <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 /> 77 <br /> PUMP INSTALLATION: Contractor _ <br /> Type of Pump--� ic.',.` H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done !` : s r _ /-'"�. t '` •' - <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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit 1 <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 for Grout Inspection prior to_grouting and a final inspection. <br /> Signed X / :.., � L. L- 'l:( � �d_/� �L Title: t i �. a .� __ Date:/ /•'./ — <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By .. _ — Date <br /> Additional Comments: <br /> Phase II Grout Inspection P a III Fi at Inspection <br /> Inspection By— _____ Date —_ _____—__ Inspection B _ Dat//-- -7� <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By Januar 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT ! <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED {!) <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS -- - ---- <br /> PENALTY I <br /> OTHER <br /> OTHER <br /> v <br /> Received by Date Receipt No. Permit No. Issruanc Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9520 <br />