Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOFICE L%E: ... APPLICATION1. <br /> J�r <br /> i (For Non-Tran ab} ;_vocable, Suspendable) <br /> lh ;It: ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is J I <br /> made in compliance with San Joaquin County Ordinance No. 18l and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address City/Town <br /> Owner' Name Phone / J <br /> Address City C2� n <br /> Contractor's Name4,11 l� icense# Business Phone�Q� <br /> Contractor's Address - EmergencyPh e 3 ��`r 3 � t <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!11 CHLORINATION ❑ WELL ABANDONMENT ElOTHER 1:1PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ u <br /> DISTANCE TO NEAREST: Septic Tank /60 ` Sewer Lines Pit Privy <br /> Sewage Disposal Fiel� k! _1 ^Cesspool/Seepage Pit ll(} Other t <br /> Property Line Private Domestic Well /704 Public Domestic Well <br /> INTENDED USE II TYPE OF WELL <br /> ❑ INDUSTRIAL it CABLE TOOL Dia. of Well Excavation <br /> u <br /> DOIl•MESTIC/PRIVATE ❑ DRILLEDIll Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing '( <br /> ❑ IRRIGATION GRAVELPACK Depth of Grout Seal <br /> ❑ CAT HODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL �I, ❑ OTHER-"'t Other Information <br /> ❑ <br /> GEOPHYSICAL l Surface Seal Installed By: �I'!`1_SQ '�Dii <br /> PUMP INSTALLATION: Contractor � S 20A S <br /> Type of Pump H.P. 7 <br /> PUMP REPLACEMENT: ;l ❑ State Work Done <br /> PUMP REPAIR: j ❑ State Work Done <br /> DESTRUCTION OF WELL: II 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 /> { <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 becomeelsubjectt,to workman's comp sation 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 call for aGrout Inspection prior to grouting and a final inspection.1p <br /> ec <br /> Signed X /•l.C.l4lti Title: f. tate: /0 //7 17 <br /> (Draw Plot Plan'on Reverse Side) <br /> �i FO DEPART ENT USE ONLY <br /> PHASE I <br /> Application Accepted By �^� Date 1J <br /> Additional Comments: <br /> I, .. <br /> Phase t rout Inspection e ; Phase II Final Inspection <br /> I <br /> Inspection By f Date Inspection By Dai <br /> IFee Is Due: ❑ ANNUALLY El PER UNIT. PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT , <br /> BILLING REMITTANCE <br /> BASE .. EXPLANATION "Y��DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE M 1 U <br /> 4 f• ,N . <br /> LESS - <br /> PRORATION <br /> IPLUS <br /> PENALTY 11 <br /> { <br /> OTHER !i <br /> OTHER II <br /> —y i <br /> I! / — �-7 <br /> Received by - _+ Date'hi. Receipt No. Permit No, Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES .1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />