Laserfiche WebLink
Applications•Will Be Processed When Submitted Properly Completed. Be T6r3165`The Application. <br /> FCR;OFFIr_F USE: APPLICATIOND NOV $ �g$� <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> 4 ENVIRONMENTAL HEALTH PERMIT SAN JOAQUHN LOCAL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY " HEALTH DISTRICT <br /> Application is hereby madetotheSan Joaquin Local Health Districtfora permitto constructand/or install thework,herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San,Joaquin Local Health District. <br /> w: <br /> Exact Site Address A City/Town <br /> Fa _ Phone •3�9. Y <br /> Owner's Name <br /> Address � R _ City f <br /> Contractor's Name Pc., fA ���7�^- _ ) 1 License# Business Phone `� Yw7 <br /> Contractor's Addrps _ , _.__ ��* --f�l �,ji' Emergency Phone <br /> I Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes �� No <br /> k 'TYPE OF WORK (CHECK): NEW WELL®'--� DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ �/ <br /> If WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION Ek"' PUMP REPAIR❑ (� <br /> P REPLACEMENT❑ <br /> FDISTANCE TO NEAREST: Septic Tank _J47-,Q Sewer Lines 1 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 /> M-tOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing � <br /> ' ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION <br /> ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION M-ITOTARY Type of Grout _ / ��(S,-, <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: contractor z <br /> ✓ ype of Pump ns �� H.P. �5 <br /> PUMP REPLACEMENT: u State Work Done ' <br /> PUMP REPAIR: ❑ State Work Done r <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth �- <br /> Describe Material and Procedure <br /> r 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 fallowing:"I certify that in the performance of the work for which this permit t <br /> is issued, I shall not employ any person in such the <br /> as to become subject to workman's compensation laws of California." <br /> f <br /> Contractor's hiring orsub-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 a Grout Inspection prior to grouting and a final inspection. <br /> Signed X _ Title: A Dal z <br /> (Draw Plot Plan on Reverse Side <br /> f <br /> FOR DEPARTMENT USE ONLY <br /> i PHASEI <br /> Application AcceptedZsll <br /> Date RO <br /> Additional Comment - <br /> Inspection P e I Final Ins ection <br /> Inspection ByDate �� _ Inspection By ateV. <br /> l <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July I &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE S _ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> F �Q �'Q O <br /> FEE Y U Q <br /> 4 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER - <br /> `� ro 3t` 535 <br /> Received by Date Receipt No. - Mrntff No. Issuance Dale Mailed Delivered .. ' <br /> APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMIT/SERVICES^m� „� 1601 E.'HAZELTON AVE.,P.O.Box 20D9 STOCKTON,CA 95201 <br />