Laserfiche WebLink
Applications Will Be ProcessedWhenSubmitted Propertyc;omplerea. tiesure IoJI n ineHPP11111i <br /> FOR OFFICE USE: APPLICATION f ✓/ ' <br /> (For Non-Transferable, Revocable, Suspendable) MY ,' <br /> PUMP&WELL <br /> -- ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance withuin County O dinc No. 186 the rules and regulations of the San JoaquiryLocal a th District. <br /> Exact Site Address •� � City/Town20, <br /> Owner's Name ' e Phone <br /> AddressCity <br /> Contractor's Name s cense Business Phone <br /> 1 <br /> Contractor's Address 7a► Emergency Phone <br /> Is Certificate of Workman's Compensation Insur ce on File With SJLHD? Yes �r No <br /> TYPE OF WORK (CHECK): NEW WEL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENTOJ <br /> �— <br /> DISTANCE TO NEAREST: Septic Tank f� Suer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit �/1�d —`" t er <br /> Property Line„ Private Domestic Well 149 00"-Public Domestic Well <br /> INTENDED USE TYPE OF WELL 2-1!� ,yf <br /> ❑ IN TRIAL ❑ CABLE TOOL Dia. of Well Excavation Lam` <br /> QMESTIC/PRIVATE DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing — <br /> ❑ IRRIGATION ,❑, GGRRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION Wit't ARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Inst lied 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 <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 performance of 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 1 141I.Lizall for a Gr spection prior to grouting and a final inspection. <br /> s � <br /> Signed Title: <br /> �` Date: ' <br /> (Draw Plot Plan on Rev se Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE f I� J <br /> Application Accepted By Date <br /> Additional Comments: <br /> as It Gina.411,11rispection as III F' al inspection g� <br /> Inspection By - Date �-�Z —�f Inspection By 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 REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTE AMOUNT <br /> FEE <br /> LESS <br /> rr+VRATIOr?� <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received byReceipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2008 STOCKTON,CA 95201 <br />