Laserfiche WebLink
r Applications Will Be Processed When Submitted Properlycompletea. tse sure Ioal Ine <br /> . t <br /> .+YNrr.atly" <br /> OR OFFICU"E: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP <br /> &W� 'Will I <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or install the work herein described.This application is <br /> made in compliance An San J�aquin Co my Ordinance Np. 1862 and the rules and regulations of the San a n L c I Health District. <br /> Exact Site Address eel City/Town // f <br /> Owner's Name S Phone Y -- <br /> Address City <br /> Contractor's Name icense l Business Phone_ �� <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes A No <br /> TYPE OF WORK (CHECK): NEW WELL;K DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ t <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank -'51Q Sewer Lines sS'd f! Pit Privy <br /> Sewage Disposal Field f� /+ Cesspool/Seepage Pit Other �— <br /> Private Domestic Well Public Domestic Well <br /> Property Line�L' 4 <br /> INTENDED USE TYPE OF WELL 01 <br /> E] INDUSTRIAL I] CABLE TOOL Dia. of Well Excavation it <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> C1DOMESTIC/PUBLIC 11DRIVEN Gauge of Casing — r <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal So e �2 f St �� <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 H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <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 i <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 performanceof 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 forwhich this <br /> permit is issued, I shall employ pe ns subject to workman's compensation laws of California." <br /> I wil all for a out pec ' for to grouting and a final inspection. <br /> Signed X Tltle: Date: <br /> (Draw Plot Plan on Reverse e) <br /> FOR DEPARTMENT USE ONLY r <br /> PHASE I y� J A� (� ���E <br /> Application Acce ted By `� H f[ - Date <br /> Additional Comm s: <br /> se 11 Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By NIA Date <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UN ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Ju{y i &Received By July 31 <br /> REMIT <br /> BASE EXPLANATIO BILLING_ –REMITTANCE - $ AMOUNT DUE CHECKED <br /> DATE DATE _REMITTED AMOUNT <br /> f— _ <br /> cru <br /> FEE Lk <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> � Id <br /> Received by Date Receipt No. Permit No. Issulgince D to Mailed Delivered <br /> APPLFCANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 85201 <br />