Laserfiche WebLink
bm <br /> Appiications Witi-Se Pr_a�cess�when SuAPPL�CATION <br /> EFOR OFFICE USE. <br /> ( jD 1�4� (For Non-Transferable,Revocable,Suspendable} PUMP&`tWELL <br /> nom fENVIRONMENTAL. HEALTH PERMIT <br /> WATEII QUALITY ., " <br /> .(COMPLETE IN TRIPLICATE) s' <br /> Application is hereby made an <br /> the San Joaquin Local Health Disti$S f permit to construct an rules and <br /> regulations oftthe San Joaquinalithework ln ocal-Heath9ist,This riotQl�on Is <br /> City/Town <br /> et l <br /> made in compliance with 5an�Joaquin County Ordinance o. � <br /> COs ..Lai YGs— � <br /> Exact Site Address e-V3)} / Phone x <br /> D7 n�C� ✓ s .�/c9 t <br /> CityI <br /> Owner's Name -74 <br /> .� <br /> Addresses I�usiness Phone �" l <br /> µ License# <br /> s Contractor's Name . Emergency Phone <br /> Contractor's Address Yes No 1 <br /> t -d <br /> 1s Certificate of Workman's Compensation Insurance on Ile❑With SJRL CONDITION❑ DESTRUGTION❑ <br /> TYPE OF WORK (CHECK J: NEW WELL❑ DEEPEN <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ® PUMP REPAIR <br /> REPLACEMENT❑ Sewer Lines . Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank ,Cesspool/Seepage Pit Other <br /> Sewage Disposal Field Public Domestic Well <br /> 4- Property Line Private Domestic TYPE OF WELL Well. <br /> INTENDED USE ❑ CABLE TOOL Dia. of Well Excavation <br /> 1 ❑ INDUSTRIAL 13 DRILLED Dia. of Well Casing <br /> ElDOMESTIC/PRIVATE [3 DRIVEN Gauge of Casing <br /> { ClDOMESTIC/PUBLIC ❑ GRAVEL PACK' -Depth of-Grout-Seal- <br /> t ® IRRIGATION ❑ ROTARY Type of Grout <br /> ❑ CATHODIC PROTECTION ❑ OTHER Other Information <br /> ❑ DISPOSAL SurfaceSeal Installed By: <br /> ❑ GEOPHYSICAL 4 <br /> Contractor H.P. <br /> PUMP INSTALLATION: Type of Pump `� <br /> i R'State Work Done <br /> PUMP REPLACEMENT: ❑ State Work DoneI, <br /> PUMP REPAIR: Well Diameter Approximate Depth <br /> � <br /> DESTRUCTION OF WELL: _ <br /> iDescribe Material and Procedure <br /> I hereby certify that I have prepared reisu ations of the San Joaqu noLo alll Health District l be done in cordance with San Joaquin Coun y <br /> Q <br /> rk <br /> ordinances, state laws, and rule 9 g.„ V <br /> Home owner or licensed agent's signature certifies the follow in 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';hiring orsub-contracting signtattuere to twos the following: <br /> sa ertif that i the p rmam <br /> permit is issued, I shall employ personsance of the work for which this <br /> s <br /> I will call for a Grout Insp cti n rfof o routing d a final inspection. <br /> h .� Date: <br /> Signed X (Draw lot-Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> d Date,�5,.�1 <br /> PHASE <br /> Application Accepted By <br /> Additional Comments: ase III Final Ins ection <br /> Phase IhGraut Inspecilon *. pate t <br /> T' <br /> Date Inspection By <br /> inspection By <br /> 13 January 1 &Received By January 31 ❑-July 1 &Received REMIT July 31 <br /> IT <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 13 PER SITE EACH REMITTANCE AMOUNT DUE CHECKED <br /> 1 BILLING <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS 0 <br /> PRORATION r� <br /> PLUS <br /> PENALTY <br /> OTHER s"/�—fj O •{ p!�! /® <br /> Q OTHER S Z <br /> Receipt No <br /> suanc Mailed Delivered ' <br /> Received by Date � Permit No. 1601 E.HAXELTON AVE.;P.O.Box 2099 STOCKTON,CA.95291 <br /> ENVIRONMENTAL: .. ENYIRONENTAL HEALTH PERMIT/SERVICES <br /> APPLICANT—RETURN ALL COPIES TO <br />