Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendabie) <br /> PUMP&WELL $ <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health Districtfora permitto construct and/or install thework herein described.This application is <br /> made in compliance with San Joa uin Court y rdinanc No. 1862 and t ru s and regulations of the San Joaquin Local Health District.' <br /> Exact Site Address -� t �� City/Town <br /> Owner's Name Phone. - <br /> Address -1-1 G� L wt-sxWO, _ City..+,.. <br /> Contractor's Name "' License#Y Business Phone ) <br /> Contractor's AddressEmergency Phone .5 � ,�; <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes? No <br /> TYPE OF WORK (CHECK)---NEW WELL It:- "DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <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 5 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 /> 11DOMESTIC/PUBLIC ❑'DRIVEN . Gauge of Casing <br /> 11 IRRIGATION It GRAVEL PACK Depth of Grout NJ <br /> ❑ CATHODIC PROTECTION DL ROTARY Type of Gr t <br /> ❑ DISPOSAL ❑ OTHER Other Inform n <br /> ❑ GEOPHYSICAL Surface Seal Installed By:. <br /> PUMP INSTALLATION: Contractor r <br /> Type of Pump H.P. <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 /> ' 1 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:"I certify that in the performance of the work for which this permit <br /> is issued, 1 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Gfout.lnspection prior to grouting and a finalinspection. <br /> Signed X Title: �.�r _ Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By ' DatE. <br /> y <br /> Additional Comments: <br /> P se Grout Inspection f �, 1, w - Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: 13ANNUALLY ❑ PER UNIT ❑ PER SITE ElEACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 - <br /> REMIT <br /> - BASE EXPLANATION FGLINREMITTANCE $ AMOUNT DUE CHECKED <br /> ATE DATE REMITTED AMOUNT <br /> O -- <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS T. - <br /> PENALTY 1 <br /> OTHER <br /> OTHER rt r <br /> Leedwed y OWN Receipt No.' Permit No. 7 >Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2049 STOCKTON,CA 95201 <br />