Laserfiche WebLink
Applications Will Be Processed When Submitted Properly completea. tie sure rosign 1neMPTAlualru— <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL. <br /> ? <br /> ENVIRONMENTAL HEALTH PERMIT T <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> istrict fora permitto construct and/or install the work herein described.This application is <br /> Application is hereby made to the San Joaquin Local Health D <br /> made in compliance with Joaqulin Coun y OrdinfLnce No. 1862 and the rules and regulations of the an aquin Local Health District. f <br /> Exact Site Address City/Town ew <br /> I� <br /> Owner's Name Phone <br /> Address City /u <br /> Contractor's NameLLL' �' - - License# ✓� Business Phone 6 3 e <br /> Contractor's Address r dc�ri7 d Emergency Phone '5! �;4 E <br /> Is Certificate of Workman's Compensation Insu ance on File With SJLHD? Yes 1� No C> <br /> TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ElWELL ABANDONMENT 13OTHER 13PUMP INSTALLATION El PUMP REPAIR❑ <br /> REPLACEMENT®-_ Jt <br /> DISTANCE TO NEAREST: Septic Tank 7 0' _ Sewer Lines Pit Privy tY.E c'L <br /> Sewage Disposal Field� _� Cesspool/Seepage Pit Other <br /> Property Line f Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL <br /> ❑ 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 Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout I <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <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 /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state IawO-and rules and regulations of the San Joaquin Local Health District. Q( <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit Q <br /> H 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 or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shalt employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout s clion prior to grouting and a final inspect' . <br /> i Signed X <br /> Title: Date: <br /> N` (Draw Plot Plan on Reverse Side) <br /> II FOR DEPARTMENT USE ONLY <br /> I l <br /> PHASE I I , ��—o <br /> Application Accepted By I Date <br /> Additional Comments: I <br /> �i Ph se Ill Final Inspection <br /> Phase II Grout Inspection pate�� — <br /> Inspection By n� Date Inspection By <br /> Feb IS DUB: 13 ANNUALLY .111 ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ElJuly 1 &Received <br /> By July 31 <br /> 4 L BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEEs�'i <br /> f LESS IDI <br /> PRORATION �f <br /> PLUS ill <br /> PENALTY <br /> OTHER <br /> A <br /> OTHER <br /> _ v e Permit No. - is.ua ce Date Mailed Delivered <br /> Received by Date Receipt No, <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTALHEALTH PERMITISERVICES 1601 E.HAZELTON AVE..P.O.Box 2009 STOCKTON,CA 95201 <br /> II <br />