Laserfiche WebLink
.., <br /> •,f Applications Will Be Processed When Submitted Properly <br /> APPLICATION I , <br /> .FOR FILE USE: PUMP&WELL16 (For Non-Transferable,Revocable, 5uspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) i <br /> Application is hereby made to the San Joaquin Local HealthlDost1862 and the rutles and regulations oftheSan Joaquin lLocal HealtthTDistrrihis cpljcation Is If <br /> made in compliance with San Joaquin County Ordinance City/Town <br /> Exact Site Address Phone _ �.�— <br /> Owner's Name ! p City <br /> Address 6 License# 7J�f?__-5.siness Phone <br /> Contractor's Name ; Emergency Phone <br /> Contractor's AddressNo S <br />` Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes s <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITIONDESTRUCTION❑ <br /> ❑ PUMP INSTALLATION PUMP REPAIR <br /> WELL CHLORINATION 1:1 WELL ABANDONMENT ❑ OTHER ❑ <br /> REPLACEMENT❑ Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank CSer Lines esSewer ��--- <br /> spool/Seepage Pit Other <br /> Sewage Disposal Field �y�y Public Domestic Well <br /> Property Line_ Private Domestic Well __!—� <br /> INTENDED USE TYPE OF WELL �� SCS r <br /> -'^ CABLE TOOL - - Dia. of Well Excavation Q� <br /> 13 INDUSTRIAL ....... <br /> ! _, - Dia- of Well Casing <br /> 13 DRILLED <br /> DRILLED ,- " <br /> JRDOMESTIC/PRIVATE f �' DRIVEN Gauge of Casing 50 <br /> ElDOMESTIC/PUBLIC' ❑ GRAVEL PACK Depth of Grout Seal <br /> IRRIGATION ❑ ROTARY Type of Grout <br /> j <br /> 11 CATHODIC PROTECTION Other Information <br /> 11DISPOSAL E] OTHER <br /> Surface Seal Installed By: <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor H.P. <br /> � Type of Pump <br /> ❑ State Work Done <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: Approximate Depth <br /> DESTRUCTION OF WELL: <br /> Well Diameter <br /> Describe Material and Procedure <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 /> 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 for which this permit <br /> compensation sub)ect to <br /> is issued, I shall not employ any person insuch <br /> following."I certify that in performance of helaws work of forwlh'ioch this <br /> Contractor's hiring or sub contracting signature certifies <br /> permit is issued, I shall emptoY persons subject to workman's compensation laws of California." <br /> 1 will all for a Grout inspection rl to grouting and a final inspection. pate: <br /> i ���� Title: <br /> Signed X — (Draw Plot Plan on Reverse Side) <br /> _.FOR EPARTMENT USE ONLY--- --•k- Date <br /> ' <br /> PHASEI <br /> i Application Accepted By <br /> Additional Comments: Phase Ili Final Inspection <br /> has. 11 Grout Inspection Date <br /> i pate� 2—�— Inspection By . <br /> Inspection By 31 <br /> ❑ PER UNIT ❑ PER SITE -❑ EACH ❑ January 1 &Received By January 31 ❑ July t &ReceivedEMl�By uly <br /> Fee IS Due: ❑ ANNUALLY CHECKED <br /> - BILLING REMITTANCE I AMOUNT DUE <br /> DATE REMITTED AMOUNT <br /> BASE EXPLANATION <br /> DATE y <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY ' <br /> r <br /> OTHER <br /> OTHER t —7 g <br /> i r C> 7 <br /> Issuance Date Mailed Delivered <br /> l. Receipt No. Permit No.m= 1 <br /> Received 6y Date - 1601 E.HAZELTON AVE.,P.O.Box 2009' STOCK N.�A 9 <br /> APPLICANT RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERYICES (n, BP <br />