Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. t <br /> FOR.-OFF1�USE:'` APPLICATION <br /> (For Non-Transferable,'Revociible, Suspendabie) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance vfifth San Joaquin County,Ordinance No. 1662 and the rules a egulations of the San-Loaquuiin�Local Health istrict. <br /> Exact Site Address O.0 L� , @ City/Town (( <br /> Owner's Na n Phone 03 u o, <br /> Address 0_ t f City T = c>7s -74;& <br /> Contractor's Name W � License# Business Phone qCS 2,q%' X33 Z- <br /> Contractor's Address &X$711•F 7 Z5 f 'Emergency Phone -409 2X? 313 Z vv <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes f No <br /> TYPE OF WORK (CHECK): NEW WELEV' DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ t <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR <br /> REPLACEMENT❑ + � <br /> DISTANCE TO NEAREST: Septic Tan Sewer Lines PgPrivy i <br /> ,v/d Ca 4000"/ - Sewage Disposal Field �� Cess ool/Seepage Pit �A .,tier . . Other <br /> s <br /> J .` <br /> SWR Property Line! V Private Domestic Well Public Domestic Well SA+—%� <br /> INTENDED USE zall TYPE OF WELL <br /> INDUSTRIAL ,.f"u G ❑ 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 Seel <br /> ❑ CATHODIC PROTECTION .❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: AI(OW 5 <br /> PUMP INSTALLATION: Contractor WXZ`Q #tA– (?_.1 D <br /> Type of Pump VQZ'42-T4 �u�-f3+•J t H.P. o &tom <br /> PUMP REPLACEMENT: ❑ State Work Done Q <br /> PUMP REPAIR: ❑ State Work Done G <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 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 forwhich this <br /> permit is issued, I shall employ,persons subject to workman's compensation laws of California.". <br /> ill h for �j�ou`t I ection rl �1o�glrouting and a final inspection. - r <br /> Signed X �7�- ' _ j'V Title: ` _ Date: <br /> {Draw Plot Plan on Revers. . <br /> ^ ,dry •i, :.." ,.*1 <br /> + I FOR DEPARTMENT USE ONLY <br /> PHASE I i! <br /> Application Accepted By Date <br /> s ' <br /> Additional Comments: <br /> Phase II Grout Inspectiona ill F' InsRection <br /> Inspection By Date Inspection B� "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 /> .BASE EXPLANATION BILLING .REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE ,REMITTED AMOUNT r <br /> ©0 <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER - - <br /> OTHER 4 <br /> 'k <br /> Received by 'I Date - Receipt-No. - - Permit No. - - Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,A.O.Box 2004 STOCKTON,CA 95201 <br />