Laserfiche WebLink
�+gpptrcattonsV7iIlBeProcessed When Si Completed:Be Sure To Sign The Appn <br /> "FOR OFFICE USE: APPLICA-TION n - <br /> + (For Non-Transferable, Revocable, Suspendable) _ <br /> c ENVIRONMENTAL HEALTH PERMIT PUMP&WELL R i <br /> ,(COMPLETE IN TRIPLICATE) WATER QUALITY <br /> tApplication is hereby made to the San Joaquin Local Health District for a permit to consf�uct and/or install the work herein described.This application is x <br /> made in compliance with San Joaquin C nt rdinance No. 18162 and the rules and regulations of the San Joaquin _oval Health.District. <br /> Exact Site Address City/Town <br /> Owner's Name <br /> -Phone <br /> ( Address �. City <br /> Contractor's Name Licerr e# 3� pr.� Business Phone 'Z�t] <br /> Contractor's Address gen y Phone 2�4- � w <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK); NEW WELA. DEEPEN ❑ RECONDITIONO— DESTRUCTION❑ � <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONA PUMP REPAIR❑ <br /> REPLACEMENT❑ I <br /> DISTANCE TO NEAREST: Septic Tank ®f ��'� <br /> P _ Sewer Lines Pit Privy 6- <br /> Sewage Disposal Fief Cesspool/S�page Pit Other <br /> Property Line�Q Private Domestic Well Public Domestic Well <br /> INTENDED USE <br /> TYPE OF WELL °i <br /> ❑ INDUSTRIAL ❑ CABLE TOOL <br /> Dia. of Well Excavation <br /> KDOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION <br /> GRAVEL PACK Depth of Grout Seal <br /> ElJ <br /> CATHODIC PROTECTION KROTARY Type of Grout '� r <br /> ❑ DISPOSAL ❑ <br /> OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal installed By: <br /> PUMP INSTALLATION: Contractor <br /> PUMP REPLACEMENT: <br /> Type of Pump H.P. rn 4 <br /> ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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:"1 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 /> per it is issued, l shall a play per ons subject to workman's compensation laws of California." � <br /> a <br /> I ill cal n rout In ection fpr to grouting and a final inspection. <br /> Signed X G�� t <br /> Title: _gnAnllph. Date: i <br /> (Draw Plot Plan on Reverse Side) <br /> . i <br /> FOR DEPARTMENT USE ONLY. <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: ?J+c , r 7 r� t c <br /> I. <br /> Pse II Grout Inspection P a Ill Final Inspection <br /> Inspection By I; Date '� `�" Inspection By Date I <br /> FEE IS DUB: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> i DATEDATE REMITTED AMOUNT DUE CHECKED i <br /> FEE <br /> AMOUNT 1 <br /> J5 k�" <br /> LESS V <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> t <br /> OTHER { <br /> OTHER <br /> f <br /> Received by Date Receipt NOL Permit No Issuance Date <br /> Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO:, ENVIRONMENTAL HEALTH PERMIT/SERVICES `1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 _ <br />