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,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL-HEALTH PERMIT <br /> WATER QUALITY.,,., <br /> (COMPLETE IN TRIPLICATE) 'N . ;, <br /> Application is hereby made to the San Joaquin Local Health District for a.permittoconstruct and/or install ithe 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 Joaquin Local Health District., <br /> Exact Site Address 3`� S� WA-r,3:-_% Lao P+O. City/Town -_X <br /> Owner's Name <br /> �,/./�! S' ��tCoR P, Phone' <br /> 4 V � <br /> Address „'�.3s ...a ;. City <br /> Contractor's NameE1ji D_ ' F 'License# ` Business Phone 4 " 3 3 3 <br /> ' .L(C_Ez DiZ Y`Emer enc Phone " �' Iw3:' .• .: :�:t, <br /> Contractor's Address g y <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK;(CHECK): NEW WELL❑ DEEPEN ❑ r ' RECONDITION❑ ' DESTRUCTIO �ja , <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 Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL pia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE Cl DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC 11DRIVEN Gauge�of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth 6f Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information ` <br /> i ❑ GEOPHYSICAL Surface Seal Installed By:' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump, H.P. ry <br /> j PUMP REPLACEMENT: ❑ State Work Done t V <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /># l <br /> I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> I ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. . . <br /> i <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 /> Contractor's hiring or sub-contracting signature certifies the following:"1 certify that in the performance of the work forwhich this <br /> permit is issued, 1 shall employ persons subject to workman's compensation laws of California." <br /> ` •I will call for1ut Inspection prior to grouting and a final inspection. - <br /> Signed X <br /> p i Title: .Date: <br /> (Draw Plot Plan on Reverse Side) <br /> :t <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �= <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase Ill Final Inspection <br /> -�.`_ .'•- , Date . ._ _� -�-�Inspection By 4` � Date <br /> - <br /> Inspection By <br /> Fee IS Due:-❑ ANNUALLY� ❑ PER UNI! ❑ PER SiTF' ❑ EACH ❑ January 1 S Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> - r ,� -• -^ '- „BILLING REMITTANCE < .. $ AMOUNT DUE CHECKED <br /> BRSE EXPLANATIDN DATE DATE REMITTED AMOUNT <br /> FEE t <br /> LESSI' <br /> i PRORATION' <br /> PLUS " f <br /> PENALTY <br /> OTHER <br /> i <br /> OTHER r <br /> Cdr <br /> Received by D/te- -^ Receipt No.� f• y Permit No.- _ Zlssuance Date - Mailed 4elivered <br /> APPLICANT—RETURN ALL$OPIES To: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1661009 E.HAZELTON AVE.,AYE.,P.O.Box STOCKTON,CA 95201 <br />