Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Com $0e p h `� pilAtion. / <br /> FOR OFFICE USE: APPLICAT12NTM t [ <br /> '- (For Non-Transferable, Revocable,S dablJJe) <br /> ENVIRONMENTAL HEALTH PERMIYUL 28 19 PUMP&Wr=LL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY � N Ir PtiQUIN <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct an I r es ationis <br /> made in compliance wi�hl�/n,Jpaquirn County Ordinance No. 1862 and the rules and regulatio7�s of Me San Joaquin Lo a I <br /> Exact Site Address �� nl C) _.—. City/Town S7d� T <br /> Owner's Namt��_A- Phone `710 t�11 <br /> Address 7- City <br /> Contractor's Name t icense# Cl Business Phone in <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ` No . <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATI ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ 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 Welk <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE 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: r <br /> PUMP INSTALLATION: Contractor S <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT- ❑ State Work Done <br /> PU ❑ 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 fallowing:"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:1 certify that in the performance of the work for which this <br /> permit is issued, I shall emplo ersons subjec to workman's compensation laws of California." <br /> I a I or a Grout Ins cti pri r to gro ng and a final inspection. <br /> Signed Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I R�, �, <br /> Application Accepted By, �"' `�"� � Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection f3tfas Fin nspection� <br /> Inspection By Date Inspection By 'Date <br /> Fee <br /> Fee IS Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACHY ❑ January 1 &Received By January 31 ❑ July I &Received By July 31 <br /> REMIT <br /> EASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No, Issuancle Datle Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />