Laserfiche WebLink
� . <br /> Applications Will Be Processed When Submitted Properly Completed. Be sure <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable;Suspendable} PUMP&WELL <br /> 4- .,, ¢ <br /> ENVIRONMENTAL HEALTH PERMIT t <br /> � <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> I <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 <br /> made in compliance-with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquinlocal Health District. <br /> n <br /> Exact Site Address City/Tow <br /> r4 Phone <br /> Owner's Name 1 City <br /> Address C <br /> e/ License# "� Business Phone <br /> Contractor's Name <br /> Contractor's Address .Csl J - �� ` Emergency Phon <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No ` <br /> TYPE OF.WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION 13 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ElOTHER tr PUMP INSTALLATION❑ PUMP REPAIR &) <br /> C3Ni <br /> REPLACEMENT I I , <br /> DISTANCE TO NEAREST: Septic Tank _ Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other I <br /> Property Line Private Domestic Well Public Domestic Well d <br /> INTENDED USE TYPE OF WELL <br /> 11 INDUSTRIAL El CABLE TOOL Dia. of Well Excavation , <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing I <br /> I <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> d <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information ._ <br /> ❑ GEOPHYSICAL - Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor i <br /> Type of Pump H P. { <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done c <br /> if Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter g <br /> #Describe Material and Procedure <br /> I hereby certify that I have pr Jpared this application and that the work will be done in accordance with San Joaquin County y <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 forwhich 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:1 certify that in the performance of the work forwhich this 4 <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call Ior a Inspection prior to grouting and a final inspec�ion� r <br /> Signed X ?� �! Title: —{ Date: <br /> (Draw Ploi Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout Inspection Phae III Final Inspection <br /> Inspection By f Date Inspection By Date d <br /> Fee Is Due:.❑ 'ANNUALLY ❑ PERUNIT El PER SITE ❑ EACH ❑ January 1 &Received By January 31 E] JuVy t &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE I EXPLANATION DATE DATE REMITTED AMOUNT <br /> 4!f . o0 <br /> FEE <br /> 4 <br /> LESS <br /> PRORATION <br /> y PLUS <br /> 4 PENALTY <br /> OTHER <br /> OTHER <br /> 3 — t3 <br /> Received by ;Date - Receipt NO. Permit No. I uance D to Mailed Delivered <br /> APPLICANT=RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAIELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />