Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. t 8 <br /> r,FA. rFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> I 11ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> I <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <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 /> t made in compliance with San oaquinn Qounty Ordinance No. 1f 2 andt e r es and regulations of the San Joaquin Local Health District. <br /> Exact Site Addresser �`` f.)/� � )� _ City/Town -�- <br /> 1 ' <br /> Owner's Name C"t� O �� Phone <br /> Address l Y12 11 City <br /> �- I <br /> Contractor's Name tficense#.�' rf� / Business Phone <br /> Contractor's Address Emergency Phone x' <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes Nos O <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR-a, <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 ❑ CABLE TOOL Dia. of Well Excavation rl <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. _. <br /> PUMP REPLACEMENT: A�%State Work Done <br /> PUMP REPAIR, ❑ State Work Done <br />{. DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> I Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accord_an_ce with San Joaquin County <br /> ordinances, state laws, and rules and regulations of-tYie San Joaquin Local Health-District:-' <br /> Home owner or licensed agent's signature certifies the following:-'rl-'IIn the performance of the work for which this permit i <br /> is issued, I shall not employ any person in such manner s 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 w' call fora rout inspection prior to grouting and a final inspection, <br /> Signed X ,! Title: j <br /> Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPA TMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection ase III Fi a spection <br /> Inspection By . Date Inspection By Date <br /> FEE IS Due: ❑ ANNUALLY PER UNIT ❑ PER SITE El EACH ❑ January 1 &.Received By January 31 ❑ July 1 &Received By July 31 <br /> BIDING REMITTANCE REMIT, <br /> BASE EXPLANATION $ AMOUNT DUE CHECKED <br /> _ DATE DATE REMITTED <br /> AMOUNT <br /> FEE [ 7S-- o <br /> LESS 7 <br /> PRORATION <br /> PLUS + <br /> PENALTY <br /> OTHER ' <br /> OTHER <br /> f <br /> Received by Date + � DC~ x <br /> Receipi No. Permit No. Issuance Date Mailed De ered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />