Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> 4: _f �8►0'��. n- � (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> _ ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) { 1 0.9 5- �4V .WATER QUALITY <br /> Application is hereby made to the S+ nJoaqufnLocalHealth Istncforapermittoconstructand/orinstalltheworkherein_described.Thisapplicationis <br /> toted:]' <br /> made in compli n e.wi San J aquin County dina e N .1862 and the rules and regulations of the San Joa al Health District. <br />` Exact Site Add s � �- City/Town <br /> Owner's Name Phone <br /> Address l/G O City <br /> Contractor's Name I(- Z -,A2 License NB usiniss Phone <br /> Contractor's Address Emergency Phone- <br /> Is <br /> honeIs Certificate of Workman's Compensation Insurance on Fil With SJLHD? Yes_—_ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ C <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 Private Domestic Well Ya Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> i ,❑d INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> IG9►DOMESTIC/PRIVATE �__ ❑ DRILLED T Dia. of Well Casing <br /> ❑ DOf�1 <br /> w � <br /> ~ tiDRI.VEN, y ) Gauge of Casing <br /> ESTIClPUBLIC� {+A';, ❑ <br /> I ❑ IRRIGATION . ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ° ' ❑ ROTARY Type of.Grout O <br /> I ^ �c tom• <br /> t ElDISPOSAC'-�,, ', � ❑,OTHER Other Information D <br /> ❑ GEOPHYSICAL ,`. _ Surface Seal Installed By: -0 <br /> PUMP INSTALLATION: '?'���" Contractor pet.e <br /> Type of Pump 4 _ H.P. l w- <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 /> R <br /> 1 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> L 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 /> I will all for a Grout Inspection prior 1 ro tin an finam p oq__ <br /> i Signed X. e: Date: <br /> ri (Draw Plot Plan on Reverse Side) <br /> # FOR DEPARTMENT USE ONLY <br /> PHASE I- <br /> Application Accepted By [/ Date <br /> Additional Comments: <br /> t Phase II Grout Inspection y a II Inspection <br /> a Inspection By - Date Inspection By Date <br /> f Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &R eived By January 31+ El July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> k BASE. EXPLANATION DATE DATE REMITTED AMOUNT DUE CPECKr=D <br /> AMOUNT <br /> s <br /> I FEE <br /> LESS k <br /> PRORATION ' <br /> PLUS <br /> PENALTY . <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. - Permit No. _ ._ Islimance Datt I Mailed Delivered , <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />