Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Nan-Transferable, Revocable,Suspendable) / PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is herebymadetotheSanJoaquinLocalHealthD•+strictforapermittoconstructand/orinstallthework herein described. District. <br /> i trio.cation is <br /> made in compliance with San Joaquin County Or inance No. 1862 and the rule and regulations of the San Jo n Local Health District. <br /> Exact Site Address City/Town <br /> Phone. <br /> Owner's Name a <br /> ~ c/f <br /> Address d City <br /> Contractor's Name <br /> License# ? ��l Business Phone <br /> - � 1 <br /> Contractor's Address Emergency Phone ` <br /> Is Certificate of Workman's Compensation In urance on File With SJLHD? Yes NO <br /> TYPE OP WORK (CHECK): ^ NEW WELL DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ <br /> WELL CHLORINATION 1:1WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 13 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 /> TYPE OF WELL <br /> INTENDED' USE L r <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> pMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ._ _.�S ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal 5U <br /> 13 CATHODIC PROTECTION I ROTARY Type of Grout <br /> ❑ DISPOSAL i ❑ OTHER Other Information w <br /> ❑ GEOPHYSICAL' Surface Seal installed By: <br /> PUMP INSTALLATION: Contractor O <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: <br /> i ❑'State Work Done <br /> PUMP REPAIR: PIA ❑ State Work Done. `x 4 <br /> DESTRUCTION OF WELL: ""`- Well Diameter ' V Approximate Depth <br /> Describe Material and Procedure <br /> i <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 forwhich this permit <br /> i 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 /> I will Cal a Grou inspection p for to grouting and a final inspection. <br /> Signed X Title: Date: Z <br /> (Draw of Plan on Reverse Side) <br /> x <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / y <br /> Date <br /> Application Accepted By_z9".,,1 <br /> Additional Comments: <br /> Pha liWr .pection Phas tll Final Inspection <br /> Inspectionfay Date Inspection By. <br /> y Date <br /> I <br /> Fee Is Due: 11ANNUALLY PER UNIT ❑ PER SITE EACH ❑ January 1 &Received By January 31' ❑ July 1 &Received By July 31 <br /> „�, REMIT <br /> ... �. h.=.- - .. <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> I -BASE EXPLANATION DATE DATE .,REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> I OTHER _ <br /> OTHER <br /> Received by Date - Receipt No Permit No. Issuance Date Mailed Delivered .. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELT4N AVE.,P.O.Box 2!109 -STOCKTON,CA 95201 <br />