Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.' ! <br /> FOR OFFICE USE: APPLICATION <br /> (For Nonii;Transferable, Revo able,Suspendable) <br /> ENVIRO�NTAL LTH PERMIT PUMP&"WELL - 1 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.Thistiop Is r <br /> made in compliance with1 San Jo a in County rdinanc No. 1882 and the rules and regulations of the San Joaquin Local Health District, <br /> Exact Site Address '7 Z eV �L - City/Town <br /> Owner's Name Phone <br /> Address ` City <br /> Contractor's Name Lice�sl � Busines Phone <br /> Contractor's Addressergency Phone 57A!? erU <br /> Is Certificate of Workman's Compensation InsuranC_e on File With SJLHO? Yes 4--- No } <br /> TYPE OF WORK (CHECK): NEW WELL 2�',DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ i <br /> WELL CHLORINATION__ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 11PUMP REPAIR❑ <br /> REPLACEMENT❑ + <br /> DISTANCE TO NEAREST: Septic Tank 414�2 Sewer Lines - - Pit Privy <br /> Sewage'Disposal Field Ces I/Seepage Pit Other <br /> FT Property Lin Private Domestic Well Public Domestic Well <br /> INTENDED USE T�YP OF WELL I <br /> INDUSTRIAL '&WABLE TOOL 11lialit of Well Excavation Jv r <br /> 9"L16Ut <br /> MESTIC/PRIMATE ❑ DRILLED of Well Casing 17g <br /> ❑ DOMESTIC/PUBLIC' — ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION = M ,: ElGRA_VEL PACK Depth of Grout Seale C1 f <br /> r❑ CATHODIC P O ECTION ;`ROTARY Type of Grout �! <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed y: <br /> PUMP INSTALLATION: Contractor . IN. # <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Dome <br /> PUMP REPAIR: ❑=State Work Done <br /> k <br /> DESTRUCTION OF WELL: 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 /> L ordinances,,state-laws-andrules-and�regulations-of the-San-,�lbatauLn Lora-Heal h Dls nc . <br /> Home owner or licensed agent's sig a ure certifies the following: I cbrfify�ahat in the performance of the work for which this permit j <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." r <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 four a�lGrout Inspection prior to grouting and a final inspection. / I <br /> (Signed X .PPS Title: .�^2.�J ��__ - Date: <br /> � (Draw Plot Plan on Reverse Side) <br /> F <br /> FORD ARTMENT USE ONLY <br /> PHASE I <br /> Application iion Accept B Date <br /> ,.' Additional Comments- <br /> Phase <br /> ommentsPhase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> �f <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 /> BASE XPLANATIONw/ AMOUNT DUE, CHECKED <br /> +�/� DATE DATE REMITTED AMOUN <br /> T <br /> "EE0Fr&7 4F <br /> BLESS <br /> PRORATION <br /> PLUS a <br /> PENALTY- -a '— —. _ — #• <br /> OTHER <br /> y <br /> —1Zs7 <br /> \ 1, 3 c� � <br /> Received by _ Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETORN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON;CA 95201 <br /> 1 <br />