Laserfiche WebLink
' Applications Will Be;Processed When Submitted ProperlyCompleted, tiesure Iooign I���„Ny,,,.,o...,• t <br /> ffFORCE USE: ?: APPLICATION <br /> } (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE)'.( �c�`� <br /> Application is herebymadetotheSanJoaquinLocalHealthDistrictforapermittoconstructan lorinstalltheworkhereindescribed.Thisapplicationis � <br /> made in compliance with San Joa uiLoc <br /> n County rdinance No.1862 and the rules and regulations of the San Joaquin al Health District. <br /> � <br /> eoe-At 1A <br /> Exact Site Address <br /> g� (/F Uf O L City/Town <br /> ° # <br /> 0 <br /> 0-0", Phone <br /> Owner's Na e L City p <br /> G¢So <br /> Address Business Phone <br /> Contractor's Name S License <br /> j <br /> '^— <br /> I Contractor's Address ' TL C mergency Phone <br /> k <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No j <br /> TYPE OF WORK (CHECK): NEE WELL RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION WELL ABANDONMENT 19 OTHER PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> I <br /> i REPLACEMENT❑ l <br /> I <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy � <br /> Sewage Disposal Field' ' Cesspool/Seepage Pit Other <br /> I Property Line Private Domestic Well Public Domestic Well <br /> if INTENDED USE TYPE OF WELL ri <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation_ <br /> ❑ DOMESTIC/PRIVATE ® DRILLED Dia. of Weil Casing <br /> Oq <br /> 13DOMESTIC/PUBLIC 11 DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION <br /> C1 ROTARY Type of Grout T'" _ <br /> i ❑ DISPOSAL ❑ OTHER Other Information V, <br /> fi7o K N 1CV4L Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> 1 PUMP REPAIR: ❑ State Work Done <br /> E Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> .. <br /> ' I Describe Material and Procedure <br /> -pared this application and that the work will be done in accordance with San Joaquin County <br /> I hereby certify that I have prep pp <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, 1 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 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 /> jL F I l0�Er—DF2 1` SS Title: Date: — / �O <br /> Signed X <br /> raw Plot Plan on Reverse Side) <br /> L1, 7 <br /> x FOR DEPARTMENT USE ONLY <br /> I PHASE I Date ' <br /> Application Accepted By <br /> k Additional Comments: <br /> Phase II Grout Inspectionhase III Final Inspection <br /> Inspection Date xC <br /> Inspection By Date � <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT- ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Ju}y 1 &ReceiveRdEBy July 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> L <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Date Receipt No. <br /> Perm it No. <br /> Received by Iss nce Da Mailed Delivered - <br /> IL APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERViCES <br /> . 1601 E.HAZELTON AVE.,P.O.Box 2D99 -STOCKTON,CA 95201 <br />