Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign'The Application. - <br /> FORtoFFICE USE: APPLICATION_ <br /> (For Non-Transferable,Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY ! <br /> Ir <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work'herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No.�1 62 and the rules and regu! ions f the San Joaquin LocAl Health District <br /> Exact Site Address 10 <br /> Owner's Name �� Phone A&L�- o2S�7 <br /> Address �� �_ City-- <br /> Contractor's <br /> itytContractor's Name s 'License# 0 Business Phone - <br /> Contractor's Address 114-6—47-nEmergency.Phone i <br /> Is Certificate of Workman's Compensation rance on File With SJLHD? Yes �X-- No <br /> TYPE OF WORK (CHECK): NEW KNELL Ins DEEPEN EI ' - RECONDITION❑ DESTRUCTION❑ -WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR El <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank AQo Sewer Lines Pit Privy v/^ <br /> Sewage Disposal Field _ loo Cesspool/Seepage Pit Other___ <br /> :9 <br /> Property Line Private Domestic Well Public Domestic Wel! <br /> INTENDED USE TYPE OF WELL 0 I" <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well"Casing V Tr <br /> 11DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing LU a=&O <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. <br /> PUMP REPLACEMENT: State 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 f� <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. v� <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 /> 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will all for a Grout Inspection prior.to grouting and a final inspection. <br /> Signed X Title: - Date: ;9 a0 <br /> (Dra lot Plan on Reveke Side) <br /> FOR EPARTMENT USE ONLY ! f <br /> PHASE 1 I' <br /> Application Accepted By Date <br /> Additional Comments: r 6 le <br /> l <br /> Ptj9se ! Grout Inspection Phase 111 Final Inspection�! <br /> Inspection B J Date 11 Inspection By �/�, Date <br /> I! <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 - ❑ Jury 1 &Received By July 31 <br /> BILLING REMITTANCE REMIT <br /> B $ <br /> BASE EXPLANATION DATE DATE .REMITTED AMOUNT DUE � CHECKED <br /> AMOUNT ' <br /> FEE 3 <br /> LESS <br /> PRORATION <br /> PLUS - - 4 <br /> PENALTY <br /> OTHER <br /> H <br /> OTHER - - <br /> Received by DE tel I Receipt No. Permit No issuance Date Mailed Delivered <br /> APPLICANT—RETI.IRK ALL C PFES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1801 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 + <br />