Laserfiche WebLink
licaiions Will Be p��$sse en Submitted properly Completed. Be are o <br /> FOR OFFICE USE: DE <br /> Gj MIS APPLICATION <br /> (F r Non-Transferable, Revocable,Suspendable) PUMP&W -� <br /> U1N R� IVIRONMENTAL HEALTH PERMIT f <br /> sAN �o � p�sT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) the work. <br /> Application is n describe <br /> hereby made to the San Joaquin Local dinancehNo518fi2 and trict for a pthe ales and regulations oftthe San Joaquin Local Health DistrT is riicplication is <br /> made in compliance with San Joaquin County OCity/Town StO—Ir tOn <br /> Exact Site Address .. 4686 11 ams Rd. <br /> Phone 464-7226 � <br /> Owner's Name E.A. White- City <br /> Address 267696 Business Phone <br /> same .f,n� �, 931-3210 <br /> ]V 1 <br /> � <br /> Contractor's Name OOrmant s/`Water 'S Stems License# <br /> Contractor's Address 4243 Cher r rand Ave. Emergency Phone' 0 Is Certificate of Workman's Compensation Insurance on file With SJLHD? Yes No - <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN❑❑ OTHER E O1Tl❑ PU11 MP INSOTALLAT ON® PUMP REPAIR 13 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT <br /> REPLACEMENT❑ Sewer Lines Pit Privy , <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other <br /> Sewage Disposal Field. -Public_ w «�• - -Public Domestic Well <br /> Property Line' Private Domestic Well <br /> INTENDED USE r TYPE OF WELL r <br /> ❑ CABLE TOOL Dia. of Well Excavation <br /> NDUSTRIAL RIVATE 11 DRILLED Dia. of Well Casing <br /> MESTIC/P <br /> 13 DRIVEN Gauge of Casing <br /> DOMESTIC/PUBLIC 13 GRAVEL PACK Depth of Grout Seal <br /> ❑ IRRIGATION Type of Grout <br /> 13 CATHODIC PROTECTION 13 ROTARY <br /> ❑ OTHER Other Information <br /> ❑ DISPOSAL Surface Seal installed By: <br /> ❑ GEOPHYSICAL MoormanI s Water Systems <br /> PUMP INSTALLATION: Contractor 1 <br /> I Type of Pump SLYbmex S11?le H.P. <br /> State work Done remove Jet <br /> 30tim and >_nstall new submersible' PUMA REPLACEMENT: [I State Work Done <br /> PUMP REPAIR: ApproximateDepth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> t 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 /> Hg: 1 certify that in the performance <br /> Homeowner or licensed agent's signature certifies the followino!the work for which this permit <br /> issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> is l Contractor's hiring or sub-contracting signature certifies the following:"1 certify that in the performance of the work far which this <br /> t to workman's compensation laws of California." <br /> permit is issued, I shall employ persons subjec <br /> I will call for a Grout Inspection prior to grouting and a final inspection. 9 Date: <br /> Title: <br /> Signed X (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY - ����� �1 <br /> PHASE I Date <br /> t Application Accepted B <br /> Additional Comments: ` hasgIII Final Inspection <br /> Phase it Grout Inspection Date j <br /> i inspection By <br /> ! Date Inspection By <br /> r 1 &Received By January 31 ❑-July i 8.Received By July 31 <br /> { REMIT <br /> Fee IS Due: ❑-ANNUALLY ❑ PER UNIT ❑ PER SITE EACH_ January $ AMOUNT DUE CHECKED <br /> _ - BILLING - REMITTANCE AMOUNT <br /> EXPLANATION DATE DATE REMITTED <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - - <br /> OTHER <br /> r4 OTHER <br /> Iss nca D to Mailed Delivered <br /> - Receipt No. - Permit No. - - <br /> Received by Date - 1601 E.HAZELTON AVE.,P.O.BOR 2008 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br />