Laserfiche WebLink
"t Applications Will 15VOrocessed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> I <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <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 S n Joaquin County Or nance No. 1862 and the ruI and regulations of the San Joaquin Local Health District. <br /> Exact Site Address J J � Q� /lJ�// City/Town � ,] <br /> F ` Phone v <br /> Owner's Name <br /> ze Address -� City 1/'Contractor's Name License#/ ` Bu Hess Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes A__` No <br /> TYPE OF WORK (CHECK): NEW WELL C1 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONX PUMP REPAIR C1 <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 N <br /> DOMESTIC/PRIVATE ElDRILLED Dia. of Well Casing �• <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 1 ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal �1 <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICALn <br /> Surface Seal Installed By: 5 11 <br /> PUMP INSTALLATION: Contractor lfne& e e< z4 <br /> Type of Pump H,P. z {n� <br /> I PUMP REPLACEMENT: ❑ State Work 11Done} <br /> p PUMP REPAIR: State Work Done <br /> F 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 /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br />,I Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> F is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> P <br /> 1 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 Gr ut Inspection prior to grouting and a final inspection. <br /> Signed X Title: -�� <br /> Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By * _. 1�• Date <br /> Additional Comments: _ <br /> Phase II Grout Inspection (was ll Final Inspection! <br /> Inspection By Date Inspection 8y ` to T� S <br /> i <br /> 1-2 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ly t &Received By July 31 ; <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE PATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT i <br /> FEE <br /> LESS J <br /> PRORATION Il <br /> PLUS <br /> PENALTY <br /> i <br /> OTHER <br /> OTHER <br /> -79 <br /> 0333 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered - <br /> APPU.,CA,N.T=R�ETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA2EL70N AVE.,P.O.box 2009 STOCKTON,CA 9524' <br />