Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. BeSureToSignTheApplication. <br /> FOR OFFICE USE: R{ APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> ' <br /> (COMPLETE IN TRIPLICATE) >I-f t1u11._A-Aiv WATER QUALITY <br /> I Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Or mance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 10 015Ey><N cJ k A VL JJ!!NQ JFAn City/Town /_,477Ygin P C Z4 Z Z ,(RA)I <br /> Owner's Name DCG & (CM-6L e Aj 4 Phone — /1 <br /> Address - d City �o e_ �0 N <br /> Contractor's Name LC— �1+ License# '�'"- Business Phone -/3 <br /> Contractor's Address 2F3 2 S F }�12T�� Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No 7� <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 91 OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ I <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 W <br /> I INTENDED USE TYPE OF WELL <br /> 3 ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 6 <br /> ❑ DOMESTIC/PRIVATE DRILLED - Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ GRAVEL PACK Depth of Grout Seal <br /> 11 IRRIGATION f- <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout _ NT CZFr <br /> ❑ DISPOSAL ❑ OTHER Other Information ^ <br /> �L 47LQ_- H 1 c [_ Surface Seal Installed By: —� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. VIA <br /> PUMP REPLACEMENT: 11State Work Done— <br /> 11 <br /> PUMP REPAIR: 1 ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> r Describe Material and Procedure 1 <br /> rI 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 /> j Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit IC <br /> i 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 /> r permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> f I will call for a Grout Inspection prior to grouting and a final inspection. <br /> r <br /> Signed X: �-� L c� S Title: Date:Z C kl AO <br /> (Draw Plot Plan on Reverse Side) <br /> c FOR DEPARTMENT USE ONLY <br /> PHASE 1 f / <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection ase III Final 1 ection� <br /> Inspection By Date Inspection B Date <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SiTF ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ - AMOUNT DUE CHECKED - <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> l LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER Y <br /> OTHER Q�! <br /> ! S <br /> Received by Date Receipt No Permit No. lbsuanc6 Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO:- ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.14AZELTON AVE-.P.D.Box 2009 STOCKTON,CA 95201 <br />