Laserfiche WebLink
Y <br /> Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTheApPlicanon, �` k <br /> FOR OFFICE use: APPLICATION <br /> (For Non-Transferable, Revocable;Suspendable) <br /> PUMP&WELL � <br /> ENVIRONMENTAL HEALTH PERMIT <br /> b <br /> 0 <br /> (COMPLETE IN TRIPLICATE) �-D, j►�, 11+I Y4 ,WATER QUALITY <br /> Application is hereby madetothean oaq ca ea Is rictforapermittoconstruc an o e ork herein described.This application is <br /> made in compliance wit San Joaqui ounty O Inance No. 1862 and he r les d regulations of the San Joaquin Local Health District. <br /> Exact Site Address City/Town <br /> Owner's Name <br /> Address CityPhone <br /> ` c License# 7 Business Phonel �! <br /> Contractor's Name <br /> Contractor's Address F Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes M P4401 dV , <br /> AA — y <br /> TYPE OF WORK (CHECK): NEW WELI.x DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank �`L Sewer Lines Pit Privy <br /> - �-Sewage Disposal-Field ----Cesspool/seepage-Pit- <br /> elf Other <br /> .r <br /> Property Line W Private Domestic Well Public Domestic Well l <br /> INTENDED USE TYPE OF WELL <br /> 13 INDUSTRIAL CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE 1:1 'DRILLED Dia. of Well Casing <br /> 1:1 DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing MEMO <br /> 1 1 <br /> ❑ IRRIGATION ❑,GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL - S rface Se l Installed y: <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 /> I I hereby certify that 1 have pr l that ared this application and the work will be done in accordance with Sart Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> 1 <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performanceof the work for which this permit <br />( is issued, 1 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:"1 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 will I for a Grout I spection prior to grouting anda final inspection. <br /> Title: Date: � . <br /> Signed X <br /> raw Plot Plan on Reverse Side) <br /> I ^ <br /> FOR DEPARTMENT USE ONLY 3 <br /> cbmza <br /> PHASE I ;. Date O -3 <br /> Application Accepted By <br /> Additional Comments: <br /> It Grout Inspectionq Phase 111 Final inspection h <br /> Inspection By Date �� — l i Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July.1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED <br /> BASE EXPLANATION - AMOUNT <br /> 1 <br /> 2 j� CJ <br /> FEE : 1 <br /> k LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> t <br /> Received by. Date Receipt No.: � Permit No. Isance ate Mailed Delivered <br /> 'APPLICANT—RETURN ALL COPIES TO: 1.ENVIRONMENTAL_HEALTH PERMITISERVICE6 1601,E..HAZELTON AVE.,P.O.Box 2009 STOCKT.ON,CA 95201 <br />