Laserfiche WebLink
i. Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> rOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMA&WELL <br /> r <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordi anc No. 1862 the r and regulations of the Sa quin Local Health District. <br /> Exact Site Address City/Town <br /> Owner's Name + 1 a'l 11 Phone - <br /> Address 3 • all c City 12 0/7 I <br /> Contractor's Name ,r r A115 jlcense# Business Phone <br /> Contractor's Address Ra:n �, Emergency Phone 1 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes _._ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR C1 <br /> r 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 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 /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> El DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICALr SurfacceSeal Installed By: <br /> PUMP INSTALLATION: Contractor T -CXR c-a <br /> t Type of Pump H p <br /> PUMP REPLACEMENT: State Work Donee ch+- 8 •--�_�E 2•���. -air <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> i <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 /> r 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 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 /> t 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 call for out Inspection prior to grouting and a final inspec <br /> Signed XL Title: Date: ,Tr✓{r/J.0 <br /> (Draw Plot Plan on Reverse Side) <br /> FORIPEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date <br /> i <br /> Additional Comments: <br /> Phase Ii Grout inspection P se Final Inspectio <br /> Inspection By Date 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 /> BILLING REMITTANCE $ <br /> RASE EXPLANATION TAMOUNT DUE CHECKED <br /> PATE DATE REMITTED <br /> � AMOUNT <br /> FEE (\, <br /> LESS I <br /> PRORATION - <br /> PLUS <br /> PENALTY,. <br /> OTHER <br /> OTHER q <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 952 <br />