80-360 - Laserfiche WebLink

Home Browse Search

.......... �� Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. E.4R-OFJ10E USE: APPLICATION (For Non-Transferable, Revocable, Suspendabie) I PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY 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 made in compliance with San Joaquin County Ord n nce No.1 62 and the rules and regulations of the San Joa uin Loc 1 Health District. Exact Site Address r` �' City/Town it Owner's Name "c .,r Phone Address r City Contractor's Name License# Business Phone v � Contractor's Address Emergency Phone Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes D937� No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR 13 I REPLACEMENT❑ - DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other - Property Line- Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ` ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 13 DOMESTIC/PRIVATE E] DRILLED' + Dia. of Well Casing 4 ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing X IRRIGATION ❑ GRAVEL PACK """'"' Depth of Grout Seal 13 CATHODIC PROTECTION �❑ ROTARY " t Type of Grout ¢ ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL 1 Surface Seal Installed By: PUMP INSTALLATION: Contractor 5el ' I Type of Pump I i, H,P. i I PUMP REPLACEMENT: ❑ State Work Done ! PUMP REPAIR: ❑ State Work Done } DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this permit is issued, I shall employ persons subject to workman's compensation laws of California." I will call Jqr a Grout Inspection pri r to routing and a final inspection. Signed X �� f/}� ^�( � Title: Date: 5,,t (Draw Plot Plan on Reverse Side) 61 FOR EPARTME USE ONLY # i PHASE l { Q Application Accepted By 4� Date 1 Additional Comments: r Phase 11 Grout Inspection e� Ph se Final I ection Inspection By Date "" Inspection B),511. Date,._ � i I Fee IS Due: ❑ ANNUALLY ❑ PER!UNIT PER SITE EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE' CHECKED DA E DATE REMITTED AMOUNT k � FEE LESS PRORATION PLUS PENALTY OTHER OTHER -3 Received by I DatA Receipt No, Permit No. Is uanc Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009' S7oCKTON,CA 95201-