Laserfiche WebLink
Applications Will Be Processed When Submitted ProperlyCompleted. Be SureTo sign 1neAppncaiii <br /> f FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> Arif PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> j <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <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 Co' nty Ordinance No. 186 and the rules and regulations of the San Joaqui Lo ai,HIt Distr'sct. <br /> Exact Site Address eF City/Town <br /> f Owner's Name Phone <br /> Address �+ eel - p�.�.� 'City <br /> Contractor's Name ���f-AYI�� lcense# ler Business Phone �- �11 <br /> Contractor's Address +� Wd Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With �dLHD? Yes 74 No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION CJ DESTRUCTION❑ <br /> WELL CHLORINATION 13WELL ABANDONMENT ElOTHER 11PUMP INSTALLATION;R PUMP REPAIR❑ pa <br /> F REPLACEMENT❑ 1 <br /> i <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field r Cessppol/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic WeII d <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> l <br /> ❑ DOMESTIC/PUBLIC 11DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal.Installed.B. <br /> I PUMP INSTALLATION: 1 Contractor --�^'� <br /> Type of pump dam H.P. <br /> PUMP REPLACEMENT: 191 State Work Done <br /> IR A4W Z91 Aii <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter K Approximate Depth <br /> Describe Material and•Procedure <br /> f <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 /> 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, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> 4 Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> I permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I I call for a Grout Insp'ct� ria to grout g an a "nal inspection. a [} <br /> 6 4 �/ <br /> Signed X Itle: Date: iii <br /> (Draw Plot n on Reverse Side) <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> PHASE r <br /> Application Accepted By <br /> ._ � J/\_ /!.. Date..0 � <br /> I Additional Comments: <br /> Phase II Grout Inspection Phase 111 Final Inspection <br /> Inspection By Date Inspection By Date <br /> I <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 /> {- 'I BASE EXPLANATION BILL4NG REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> Q <br /> FEE 'I045 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER ; <br /> k OTHER <br /> -a{ <br /> c Received by - Date Receipt No. iNo. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,GA 95201 <br />