Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOy;OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> 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 is <br /> made in compliance with San J a uin ounty Ordinance N/ . 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address �✓� City/Town <br /> Owner's Name Phone ""& <br /> Address City AdIWO C� <br /> J/ �ya <br /> Contractor's Name .0 �`L fi License# ?OW Business Phone <br /> Contractor's Address In W,!5� "6F VWe P,� __ Emergency Phone .1 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No W <br /> TYPE OF WORM( (CHECK): NEW WELL 0 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION Q-'PUMP REPAIR❑ <br /> REPLACEMENT 8— <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 urface Seal Installed By: <br /> PUMP INSTALLATION: Contractor c e �. <br /> Type of Pump Xflll? �7H.P. f <br /> PUMP REPLACEMENT: ❑ State Work Done 62 a,� - ZA1Y'XFVZ, !dJK ayz <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 fallowing:"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�C _ <br /> rout I e J nor to grouting and a final inspection.. <br /> g ��Cl1!/l C /� Date5Jr Si ned XE4� Title: <br /> (Draw Plot Plan on Reverse Side) <br /> FO DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By Date 1 <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By `r ate <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT M PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> IV DATE DATE REMITTED <br /> AMOUNT <br /> dr <br /> FEE y� v <br /> LESS <br /> PRORATION ryt <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> JA <br /> C M/'V74 t��7GS' '"7y-►rob /117q <br /> Received by Date 0 Receipt No Permit No. issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />