Laserfiche WebLink
Applications Will Be Processed When Submitted ProperlyCompleted. Be Sure 10 sign Iner�pprcauvn. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or install the work herein described.This ap lication is ; <br /> made in com lance with San Joaquin Cou ty Ordinance No 1862 end the rules and reg lations of the San Joaquin Local Health District. <br /> Exact Site Addy ss 80�� © [ tt iy/7own " <br /> Owner's Name V e >y Phone `f Q <br /> 10 <br /> Address City <br /> Contractor's Name License# t �6 Business Phone <br /> Contractor's Address O rgency Phone Is Certificate of Workman's Compensationnsurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 161Q 01 Se r Lines Pit Privy <br /> Sewage Disposal Field—�d - �' Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> 11DOMESTIC/PUBLIC 11 DRIVEN Gauge of Casing uJ <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 /> 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:1 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 orsub-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 c II for a Grout Inspe n prior to grouting and a final inspection. <br /> Signed XTitle: - Date: <br /> (Dr lot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I y r Date <br /> Application Accepted By <br /> Additional Comments: <br /> Ph 1 GroutrInspection y ,P,h�as�f III Final Inspection <br /> Inspection By Date dl� 7 Inspection By oxA Date <br /> Fee Is Due: ❑ ANNUALLY -❑ PER UNIT ❑ PER SITE ❑ EACH C1January 1 &Received By January 31 © Jury 1 S Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 3 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> 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.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />