Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. tiesure Iosign Inu•app�wan�ni <br /> FOR Q NICE USE: .;APPLICATION-1 orifi- ram� • t <br /> (F nsferable, Revocable, Suspendable) PUMP&WELL I <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) inLocalHealthDistrictforapermittoconstructand/orinstalltheworkhereindescribed.Thisapplicationis <br /> Application is herebyTRIPLICATE) <br /> the San Joaqu <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 �.+� City/Town <br /> Phone <br /> Owner's Name t <br /> Address — � - _ City <br /> Contractor's Name - License# ��a�C-Business Phone s :3 <br /> Contractor's Address Emergency PhOL <br /> 1s Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION 11 DESTRUCTION <br />)l WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR �(} <br /> E 1 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank <br /> � Sewer Lines � �� f Pit Privy ��" <br /> } ---Cesspool/Seepage Pit"`°` ==7=---Other— <br /> Sewage <br /> Disposal Field "` p <br /> l Property Line /550 Private Domestic Well ---�`—Public Domestic Well '! <br /> G• t <br /> INTENDED USE TYPE OF WELL <br /> CABLE TOOL Dia. of Well Excavation lg1l �1 <br /> ❑ INDUSTRIAL -fir <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Oasing <br /> f ❑ DRIVEN Gauge of Casing I I <br /> DOMESTIC/PUBLIC <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout �����'— 7 ^ <br /> ❑ DISPOSAL ❑ OTHER Other Information l <br /> ❑ GEOPHYSICAL Surface Seal Installed By: +� <br /> PUMP INSTALLATION:. Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: # ❑ State Work Done C <br /> PUMP REPAIR: i ❑ State Work Done <br /> 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 /> j 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, 1 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 persons subject to workman's compensation laws of California." <br /> ! will all fora Gout Inspection pri r to grouting and a final inspection. <br /> Signed X K Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Date <br /> Application Accepted By �' <br /> Additional Comments: <br /> Phase 11 Grout Inspection Ph se III Final Inspection <br /> 1 } <br /> Inspection By Date Inspection B ate / <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER.SITF ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMITuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> F <br /> FEE 3 <br /> t <br /> LESS <br /> PRORATION <br /> t PLUS m <br /> PENALTY <br /> OTHER <br /> i <br /> OTHER <br /> r " <br /> { <br /> Date Receipt No- Permit No. -issuance Date Mailed Delivered <br /> Received by1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> .APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />