Laserfiche WebLink
Applications Will Be Pr sed When Submitted Properly Completed. Be E ro Sign The Application. <br /> FOR OFFICE USE: APPLICATION ` <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT / l <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 Joaquin County Ordinance No. 1862,and the rules an regulations of the San Joaquin Local Health District. <br /> Exact Site Address ._ 7.7 /_ — - .L��t_�" f n, ;L / Cit /Town a <br /> Owner's Name ­01� Ce_ �ti (' "1 L�Z _— Phone <br /> Address - --- �� :f� r ( J City— --- <br /> Contractor's Name }� .� (License q « - _ Business Phone 1 - 7 r-/-7 E <br /> Contractor's Address;�,;,t4 _ >'1 /- , <br /> ^ - _ Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on• ile With SJLHD? Yes_- W No o J <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 18 1 <br /> REPLACEMENT❑ Q <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines _-_ Pit Priv <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 mal Installed By: <br /> PUMP INSTALLATION: Contractor 12L,)- .• ! .�. :,; <br /> Type of Pump H.P. / Li <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ® State Work Done or/ 4z C <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 <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> ! II call for a Grout Inspection prior to.grouting and a final inspection. <br /> Signed f r1 ! qtr` • . :? Title: f 1 s <br /> Date: Y <br /> F (Draw PI Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE [ <br /> Application Accepted By __v`� Date I o <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III nal Inspection <br /> Inspection By Date _ Date _Z <br /> -- _ -_- Inspection B �" <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT- ❑ PER SITE ❑ EACH ❑ January 1 ecerved By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> - <br /> LESS --- - --- - - - <br /> PRORATION <br /> WS - --- <br /> PENALTY <br /> OTHER ---- --- - - -- - ...— -- - <br /> OTHER ---- <br /> 1 � <br /> Received by Date -- ----- - -- -A,' <br /> Receipt No Permit No IssZancViDate Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES lEal c yf T,Fr Try.••« ..�-- .... - <br />