Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be $we, oig h lication. ,� <br /> FOR OFFICE USE: APPLICATI � r �d ;a �` ' <br /> (For Non-Transferable, Revocab $ S4 le) P &WELL <br /> ENVIRONMENTAL HEAL EPffT 3 Q 1981 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health Districtfora permit to constru d/onostall oelwoljMWAL described.This application is <br /> made in compliance with Ca Ordinance No. 1 fit a d the•Li1Lu and re u q ofpje� Lv <br /> Exact Site Address <br /> '� fly ty/Town/ � <br /> Owner's Name`'Y I �p �' M� Phone q1P <br /> Address 6 City <br /> Contractor's Name L, <br /> ens e# Business Phonef <br /> Contractor's Address °j Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No f <br /> TYPE OF WORK (CHECK): NEW WELL© DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRL <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ 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 <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: 3"State Work Don <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure _ <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 forwhich 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 /> Contra or sub-cont m ignature certifies the fallowing:" rtify that in the performance of the work for which this <br /> pe it 'S is e I shall empl, perso s subject to workman's comp ation laws of California." <br /> Vz <br /> I III a Inspec i n ph to grouting and a final lnspa !on. / <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI 13 <br /> Q� p <br /> Application Accepted By F-�' —! t i'�a Date I <br /> Additional Comments: <br /> Phase II Grout Inspectionhas III Final inspection <br /> Inspection 8y_ Date 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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> PATE DATE REMITTED <br /> AMOUNT <br /> FEEL� -q <br /> LESS bb <br /> PRORATION <br /> PLUS ^ ! <br /> PENALTY S tJ(/ <br /> OTHER V Uy IT <br /> OTHER <br /> o� 1 <br /> Received by Date Receipt No, Permit No, IssuAh6e Dae Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />