Laserfiche WebLink
I3 a.� . <br /> p�licaiions Will Be Protease n Submitted Properly Completed. Be sure To Sign The Application. <br /> FOR OFFICE USE: MAR APPLICATION <br /> (For Non-Transferable,Revocable,`Suspendable) PLUMP&WELL <br /> spaq oriQ-, IN LOIRONMENTAL HEALTH PERMIT <br /> ;AEALTH D%;S-f W91 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health District fora permitto construct and/or install the work herein described.This application is <br /> made in compliance with San Joaqui County Ordinance No. 1862 and the rules and regulations of the San 4oaqui Local Health District. <br /> Exact Site Address City/Town <br /> Owner's Name PhoneEll <br /> �- <br /> Address City <br /> fLicense <br /> Contractor's Name # _ Business Phone <br /> Contractor's Address cEmergency Phone W <br /> } <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ '; 'DEEPEN ❑ RECONDITION❑ W DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION Er 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 ❑ CA13LE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. A <br /> PUMP REPLACEMENT: 5VState Work Done <br /> PUMP REPAIR: ❑, 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 /> 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, 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:"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 /> 1 wt call f r out Inspection prior to grouting and a final inspection. <br /> TNile: _ .,.®,. Date: <br /> Signed X - <br /> (Draw Plot Plan on Reverse Side) <br /> t <br /> FOR DEPARTMENT USE ONLY 43 <br /> PHASE I , <br /> Application Accepted By w` �'" " ���`" Date �Q <br /> Additional Comments: <br /> Phase II Grout Inspection has 11 Final Inspection <br /> Inspection By Date Inspection By Date <br /> Feels Due: ❑ ANNUALLY ❑- PER UNIT ❑ PER S1TE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Jufy 31 . <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE - CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS Y <br /> PRORATION <br /> PLUS I <br /> PENALTY <br /> OTHER r <br /> OTHER <br /> Received by - Date Receipt No.' - Permit No. Iss ante D e Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HA?ELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />