Laserfiche WebLink
Applications Will Be Processed When Submitted Properl _Jplication. <br /> WF7USE: APPLICAT i <br /> (For Non-Transferable, Revoc usp ,1� pUMp&WELL <br /> 1111ENVIRONMENTAL HEALTH FiRMIT,-y��}� ���AL r.TRIPLICATE , I� �f �WA;ER QUALITY SA[� J��`� q� Sw work <br /> he <br /> Application is herebymadetoheSanJoaqu+n Loc al Health District for a permit toconstruc" �alf"theworkhereindescribed.Thisapplicationis <br /> made in compliance wjth S oaquin County Ordi once No. 1862 and the rules and regulations of the San Joa u n Local Health District. <br /> Exact Site Address l% lic-4z <br /> City/Yawn <br /> r" /V L H Phone <br /> Owner's Na e � <br /> Address e) c- f city ,c 5. <br /> License#�_ 3._ Business Phone SSS-!3 V - _J <br /> Contractor's Name - <br /> Contractor's Addres/27Y—Q C= -fi = �''E Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on Hie With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL 0"--DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ®' PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank !tSewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other (* <br /> Property Line Private Domestic Well Public Domestic Well '1 <br /> INTENDED USE <br /> TYPE OF WELL V <br /> �• � <br /> 11INDUSTRIAL 13CABLE TOOL Dia. of Well Excavation <br /> r <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of,Well Casing <br /> Gauge of Casing I- <br /> 0 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN <br /> El IRRIGATION C1 GRAVEL PACK Depth of Grout Seal �� { <br /> ❑ CATHODIC PROTECTION 0-VOTARY Type of Grout - +i <br /> ❑ OTHER Other Information <br /> 13 DISPOSAL i <br /> 13 GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION:' Contractor` <br /> Type of Pump " H.P. g <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: <br /> ' ElState Work Done <br /> r <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> k <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 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 iorwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> ' <br /> Signed X �� -- a ;Title: pate: 1 <br /> �? - <br /> (Draw Plot Plan on Reverse Side) . <br /> k <br /> Ikt FO D ART NT USE NLY <br /> r PHASE I % s Date 2 <br /> Application Accepted By <br /> I Additional Comments: <br /> s Ph s �11G11N <br /> pection Q� P s III Fina spection� Z �. <br /> Date _ Inspection By Date <br /> Inspection fay <br /> I Fee Is Due: ❑ ANNUALLY ❑ P ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMBASE 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 /> 7�cf7 <br /> Received by <br /> Date Receipt No. Permit No. Issuance D to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 <br />