Laserfiche WebLink
Appli4tl n41w B BWirocessed Whe 4Dmltted Properly Completed.Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> EP Q � on-Transferable, Revocable,Suspendable) PUMP&WELL <br /> J , NMENTAL HEALTH PERMIT / <br /> (COMPLETE 1N TRIPLICATE) SAN� LTH plSTP3CT WATER QUALITY <br /> Application is hereby made to the ri oaquin Local Health Districtfora permit to construct and/or install thework.herein described.This application is <br /> made in compliance-with"SanJoaquin--ount Ordinance N 1862 and the rules and regulations of the San Joaqui Locale Health District. <br /> ,,�}�� <br /> Exact Site Address. &. '%� .�% „^ City/Town <br /> Owner's Name Phone <br /> Address 2 lWo City <br /> Contractor's Name License# Busin s Phone <br /> I <br /> Contractor's Address 17 X;1 Emergency Phone <br /> Is Certificate of Workman's Compensat on Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑.. DESTRUCTION❑ <br /> �. <br /> MEL-L—CHLORINATIO WELL ABANDONMENT.❑ OTHER PUMP INSTALLATION ❑✓ PUMP REPAIR 13REPLACEMENT I <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines f Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other ., <br /> Property Line Private Domestic Well Public Domestic Well <br /> NTENDED USE TYPE OF WELL is <br /> I DUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation c <br /> D MESTIC/PRIVATE ❑ DRILLED .Dia'of Well Casing 4 s <br /> ❑ D MESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ 1 RIGATION i ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ ATHODIC PROTECTION ❑ ROTARY Type of Grout r <br /> ❑ ISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: I <br /> MP INSTALLATION: Contractor <br /> r Type of Pump r .H.P. I <br /> PUMP REPLACEMENT: tate Work Done U <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well'Diameter TM ]Approximate Depth x <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 Distr.ict.. ? <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, l shall not employ any person in such manner as to become subject to workman's compensation laws of.California." <br /> Contractor's hiring or su b-contracting signature certifies the following:v'I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subjec to workman's compensation laws of California." <br /> Ill ca for a Grout spec' n pri to gr ting and nal inspection. <br /> Signed X tie: Date: <br /> (Draw Plot an on Reverse Side) ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By ateR �I <br /> Additional Comments: <br /> Phase 11 Grout Inspection a III Fin Inspection <br /> Inspection By Date Inspection y Date. r <br /> Fee is Due: El ANNUALLY El PER UNIT El PER SITE 11 EACH ❑ January 1 &Received By J u.r,31 ❑ July i &Received By July 31 <br /> REMIT <br /> - BILLING REMITTANCE- - ,. $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> 45011 Q �® <br /> LESS <br /> PRORATION <br /> PLUS .. <br /> PENALTY <br /> OTHER i <br /> OTHER k } - <br /> l3 cf, s <br /> ,Received by - Date Receipt No. Permit No. Iss ante!] to I - Mailed Delivered, - <br /> APPLICANT—RETURN-ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />