Laserfiche WebLink
�. � <br /> Applications Will Be Processed When Submitted <br /> APPLICATION <br /> 2X� ,, FF10EUSE: (For Non-Transferable, Revocable,Suspendable) PUMP&WELL r ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY application is <br /> (COMPLETE IN TRIPLICATE) <br /> d the i s d regulations of the San Jo uin Local Health District. <br /> is hereby made to the5anJoaquinLocalHealthDistrictforapermittocon tructand/orinstallthework herein described.7hls <br /> Application No.1862 <br /> made in compliance with S n oa n County Ordin City/Town <br /> I � <br /> Exact Site Address_ , Phone i <br /> City <br /> Owner's Name <br /> Address LicenseBusiness Phone <br /> Contractor's Name Emergency Ph <br /> Contractor's Address <br /> No <br /> Of Workm n's Lampert stion Insurance on File With SJLHD?RECONDITION❑ DESTRUCTIONYes <br /> 1s Certificate ❑ <br /> I <br /> WELL DEEPEN Cl13PUMP REPAIR <br /> NEW <br /> TYPE OF WORK (CHECK): ❑ PUMP INSTALLATION <br /> WELL CHLORINATION <br /> ❑ WELL 13ABANDONMENT OTHER , <br /> REPLACEMENT 13 Septic <br /> Lines Pit Privy ; <br /> _._. Other <br /> DISTANCE TO NEAREST: Septic Tank CesspoollSeepage Pit <br /> Sewage Disposal Field Public Domestic Well <br /> Property Line Private Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ INDUSTRIAL ❑ DRILLED Dia. of Well Casing <br /> DOMESTIC/PRIVATE ❑ DRIVEN Gauge of Casing <br /> bILY— Depth of Grout Seal aQ <br /> 3° GRAVEL PACK <br /> ❑ IRRIGATION El❑ ROTARY Type of Grout <br /> ❑ CATHODIC PROTECTION ❑ OTHER Other Information <br /> 11 DISPOSAL Surface Seal installed By: r <br /> ❑ GEOPHYSICAL Contractor <br /> H.P. <br /> PUMP INSTALLATION: Type of Pump _ <br /> c <br /> ❑ State Work Done S <br /> PUMP REPLACEMENT: State Work Done proximate Depth <br /> PUMP REPAIR: Well Diameter <br /> DESTRUCTION OF WELL: <br /> - Describe Material and Procedure <br /> n Joaquin County <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Sa <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health district. <br /> g.". y of <br /> h manner as to become subject to workman's compensation laws Cali ch this <br /> Home owner or licensed agent's signature certcies the following: l certify that in the performance of the work feor which this permit <br /> 1 is issued, I shall not employ any person in such <br /> g 'I certify that in the performance o t <br /> to persons subject to workman's compensation laws of California." <br /> [ Contractor's hiring or sub-contracting signature certifies the fallowing: <br /> permit is issued, i shall employ Y p and a final Inspe <br /> /� `/ y <br /> I will call for a Grolt I ectian prior o grouting Date <br /> Title: <br /> Signed X (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY a„ <br /> t Date <br /> PHASE I <br /> F <br /> Application Accepted By <br /> Phas tll Fi I Inspection <br /> I Additional Comments: _ <br /> Phase It Grout Inspection Date � e p <br /> Date <br /> t Inspection By <br /> Inspection By Jul 1 &Received By July 31. <br /> i REMIT <br /> 'I Fee IS Due. ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Recel d By January 31 y CHECKED <br /> EMITTAN <br /> RCE $ AMOUNT DUE <br /> BILLING DATE REMITTED AMOUNT <br /> BASE EXPLANATION DATE <br /> FEE <br /> LESS ,. <br /> t PRORATION <br /> { <br /> PLUS t <br /> PENALTY .�}{ <br /> OTHER 1 <br /> OTHER �� <br /> Issuance Date Mailed pelivered <br /> l r Receipt No. Permit No. 3STOCKTON,CA 95201 <br /> ei <br /> - � Recved by Date 1501 E.HAZELTON AVE.,P.O.Box 2009 <br /> �• � '� APPLICANT—RETURN.ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ���^� <br />