Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. BeSureToSignTheAppucatlon. <br /> FOR OFFICE USE: APPLICATION <br /> 'r (For Non-Transferable, Revocable, Suspendable) <br /> � ! PUMP&WELL- <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to theSan Joaquin Local Health Districtfora permit to construct and/or instal;the work herein described.This application is <br /> made in compliance X. h San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address ��� " � �« +� �+2 —Fgeie � City/Town — <br /> Owner's Name-913, C Phone 6- <br /> Address � City � � AM <br /> �" <br /> Contractor's Name f License#n[Ci:U Business Phone <br /> Contractor's Address a ,10 a License <br /> Phone <br /> Is Certificate of Workman's Compensation Insurancw6n File With SJLHD? Yes- Z_ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <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 /> ®'VO-MESTIC/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 Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump -� c ft 121 r.. L H.P. <br /> PUMP REPLACEMENT: 25 State Work Done <br /> 4p` ,r <br /> PUMP REPAIR: ❑t1 State Work Done 12[0 <br /> DESTRUCTION OF WELL: Well Diameter F Approximate Depth <br /> r Describe Material and Procedure <br /> 1 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 following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspe prior to grouting and a final inspectio <br /> Signed X - a il-'r Title: Date: <br /> (Draw Plot Plan on Re rse Sid�e) ��� <br /> ' FO DEPART ENT USE ONLY . <br /> PHASE 1 <br /> Application Accepted By 61 Date / <br /> Additional Comments: <br /> Phase Ili Grout inspection Phase I I Final Inspection 11 <br /> Inspection By Date Inspection By Date <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 $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED ( _ AMOUNT <br /> i FEE () v <br /> i LESS <br /> PRORATION <br /> PLUS <br /> PENALTY �{ <br /> OTHER <br /> r <br /> OTHER <br /> a 3 ? <br /> Received by - - Date Receipt No. Permit No. Iss ante ate Mailed Delivered <br /> �APP_LICANT—RETURN.ALL COPIES TO: •ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009. STOCKTON,CA 95201 <br />