Laserfiche WebLink
f Applications Will Be Processed When Submitted Properly Completea. oe auTz �•n• - �r f <br /> APPLICATION �f1/// <br /> FOR OFFICE USE: (For Non-Transferable,Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL H&L'TH PERMIT <br /> WATER QUALITY ...'.. cat' in 01 �` < * lication is <br /> (COMPLETE IN TRIPLICATE) ' <br /> t Application is hereby made to the San Joaquin Local Health Districtfor apermit to const'rucfand/or install the work herein described.This app <br /> made in compliance with San Joaquin County Ordinance No.1862 and the rul 3 <br /> Town <br /> and reguiaU o,nGity/ San JoaquinL�oclaHealth District. <br /> ;l <br /> �o �. <br /> Exact Site Address <br /> Phone' <br /> Owner's Name ' 3r, s City <br /> AddressG <br /> Business Phone' l <br /> Contractor's Name d k"`^^ w� WEmergency Phone. <br /> Contractor's Address �� ""� L' Yes No t_11 <br /> Is Certificate of Workman's Compensation Insurance on File❑Wit With <br /> LHD? <br /> RECONDITION❑ DESTRUC ❑ _ T' <br /> TYPE OF WORK (CHECK): NEW WELL <br /> WELL CHLO N ❑ WELL ABANDONMENT ❑ OTHER 13 PUMP INSTALLATION PUMP REPAIR <br /> REPLACEMEJ Sewer Lines Pit Privy <br /> DISTANCE T AREST: Septic Tank, Cesspool/Seepage Pit Other <br /> Sewage Disposal Field <br /> Property Line <br /> Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> 11 CABLE TOOL ,,,, . w ,mow_ a Dia. of Well Excavation _ <br /> ❑ INDUSTRIAL pia. of Well Casing <br /> ❑ DRILLED <br /> I DOMESTIC/PRIVATE ❑ DRIVEN Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC Depth of Grout--.Seal,-_- <br /> 4' <br /> 1 ❑ IRRIGATION 13 GRAVEL PACK - <br /> ROTARY Type of Grout <br /> t ❑ CATHODIC PROTECTION ---�- -Other Information"'"` <br /> 11 DISPOSAL <br /> D'OTHER <br /> Surface Seal Installed By: <br /> 1 ❑ GEOPHYSICAL <br /> STALLATION: Contractor 47 <br /> PUMP INH.P <br /> I a Type of Pump# r r <br /> PUMP REPLACEMENT: fl.State Work pone <br /> ❑ State Work Done° , <br /> PUMP REPAIR: r 1 ` , 4a J... � Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter� �,. <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 Sari Joaquin Local Health District, <br /> x <br /> in the performance of <br /> Home owner or licensed agent's signature certifies the following:';I certify that <br /> is issued,I shall not employ any person in such manner as to become subject It o workman's commpensation laws of California." <br /> the work for which this permit <br /> j 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 /> o `2 <br /> I I c II for G t Inspection prior to grouting and a final inspection <br /> Title:��� : E Date: <br /> Signed 1 <br /> (Draw Plat Plan on Rev se Side} � 1 <br /> FO DEPARTMENT USE ONLYj+'�Q ! <br /> PHASE I — Date <br /> Application Accepted y I <br /> Additional Comme s: Phase 111 Final Inspection , <br /> hase 11.Grout Inspection t Date <br /> Date Inspection By <br /> Inspection By 1 .1 7 <br /> sEly <br /> Fee Is Due- ❑ ANNUALLY ❑ PER-UNIT El 'PER SITE- ❑ EACH" ❑ January 1 &Received By January 31 ❑ July 1 &Received MITuly 31 <br /> CHECKED <br /> EXPLANATION BILLING REMITTANCE_t. $ AMOUNT DUE AMOUNT <br /> RASE DATE DATE It -REMITTED. E <br /> FEE <br /> LESS <br /> PRORATION a t <br /> s 1 - <br /> PLUS I: s <br /> PENALTY <br /> OTHER r ' <br /> OTHER { <br /> Received by Rate Receipt No. <br /> Permfl'No.`. iss ante ate Mailed Delivered _ <br /> AZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 9526 <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM <br /> ITfSERVICES� 1601 E.H - <br />