Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> !FOR OFFICE USE: APPLICATION <br /> t� 'am (For Non-Transferable, Revocable;5uspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) ��' ( S' .K d t&& ATER 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.This application is <br /> made in compliance with San J a in County Ordinance No. 1862 and the rules an regulations of the San Joaquin Local Health District. <br /> Exact Site Address City/Town <br /> Owner's Name `� '/ 'M Phone <br /> Address ICity <br /> Contractor's Name 0) C. M License# / Business Phone'; <br /> Contractor's Address 9wCQ rgency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With AHD? Yes t� No j <br /> TYPE OF WORK (CHECK): NEW WELL❑_ DEEPEN 0 .RECONDITION❑ -"DESTRUCTION❑ (A) <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 PUMP INSTALLATION ❑. PUMP REPAIRN G} <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line 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 /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 9 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 /> PUMP INSTALLATION: Contractor + <br /> 1" Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done + <br /> PUMP REPAIR: " . State Work Done <br /> /I Ale <br /> DESTRUCTION OF WELL: ' Well Diameter Approximate Depth <br /> f Describe Material and Procedure 1 <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 /> Home owner 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:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ pers ns subject�to workman's compensation laws of California." <br /> } <br /> w' call f r a Gro ctio pr o grouts and a T I Inspect'on. <br /> Signed _ e: ' Date: <br /> (Draw Plot Wign on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _ Date 1- ' <br /> Application Accepte y <br /> Additional Comme �' <br /> Phase 11 Grout Inspection Phase III Final inspection <br /> Inspection By Date Inspection By Date. <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 /> BASE EXPLANATION —R BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE �� - <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER i <br /> OTHER <br /> f 5 /Z 7/�� v <br /> Received by Date Receipt No. ° Permit No. Iss ance D,to Mailed . Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9521 ,. + <br />