Laserfiche WebLink
r Applications Will Be Processed When Submitted Properly Completed.Be Sure To SignjheApplication. <br /> i <br /> -A-FOR 60010E USE: APPLICATION <br /> (For Non-Translerable, Revocable, Suspendable) PUMP &WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE)!/ <br /> W T R_QUALITY �=[�U <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct an <br /> d!or install thework.herein described.This application is <br /> i made in compliance with San Joaquin Codrity Ordinance No. 1862 and rules and reg lations of the San Joaquin �pcal Health District. <br /> Exact Site Address } —tet City/Town U,,IZr <br /> j Owner's Name 7 � i Cie> I Phone <br /> Address City <br /> Contractor's Name / LGI/u License �� Business PhoneF <br /> Contractor's Address Qrdlergency Phone <br /> I <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No �. I <br /> TYPE OF WORK (CHECK): NEW WELL9&' DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ I <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 DPrivate 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 /> r ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal N <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSA �)6iiG T� 7J ❑ OTHER Other Information J <br /> GEEZ PHYSICALS �s[C j�f/f�� Surface Seal Installed By: ! �. <br /> PUMP INSTALLATION: ;Contractor <br /> f Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 13State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth O <br /> f 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 C <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 forwhich 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 persons subject to workman's compensation laws of California." <br /> I will c for Group I pection prior to grouting and a final inspection <br /> Signed X Title: <br /> Date: <br /> (Draw Plot Plan on Reverse ide) <br /> a <br /> FOR DEPARTMENT USE ONLY <br /> PHASE f / <br /> Date <br /> Application Accepted By— C�A <br /> Additional Comments: <br /> ction <br /> Phase II Grout Inspectionas i nal Inspe -.� <br /> F Inspection By Date Inspection By gR,�Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT . ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REWTTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE , (4 3 (4-3 <br /> LESS <br /> i PRORATION _ <br /> PLUS <br /> PENALTY <br /> OTHER !t <br /> OTHER E <br /> R ceived by <br /> Dale Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO� ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 -STOCKTON,CA 95201 <br />