Laserfiche WebLink
g 1.' t <br /> _ � '�Applicattons Will Be Processed When Submitted Properly Completed. B e o Sign The Applica on. U <br /> FOR OFFICE USE: APPLICATION ` SEP -2 Z97 <br /> F� (For Non-Transferable, Revocable, Suspendable) 9 <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT SAN JOAQUIN LOCAL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY . HEALTH DISTRICT <br /> Appl ication is hereby madeto the San Joaquin Local Health Districtfora permitto construct and/or install thework.hereindescribed.This application is t <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District, <br /> Exact Site Address r _;2 r 0 4 jjS e Qze& City/Town Cg <br /> Owner's Name. . Phone sl_-o `_ v <br /> Address - P city- d S,-iya u <br /> Contractor's Named JLicense#. y`lG+is Business Phone_ 7 _ <br /> Contractor's Address _ oc�? .� d r , r/ _ Emergency Phone ��I�++ �' CDP ' <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes " No t <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN © RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR® M <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 a <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 /> a <br /> PUMP REPLACEMENT: ❑ State Work Done ' <br /> PUMP REPAIR: State Work Done � + <br /> - - t <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 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 /> I wit a for a Grout spe . prior to grouting and a final inspecti <br /> Signed X Title: 3t Date: '-a <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTM T USE ONLY <br /> PHASEI <br /> Application Accepted By Date 7 <br /> Additional Comments: ' <br /> Phase 11 Grout Inspection Phase III Final Inspection j <br /> Inspection By - Date <br /> v Inspection By Date` <br /> Fee Is Due: 11 ANNUALLY 13 PER UNIT i p PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Juiy 31 <br /> _ BILLING REMITTANCE $ <br /> REMIT <br /> BASE - - EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> ...,.. AMOUNT l <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER } <br /> OTHER <br /> 116cei4d by Date FTeceipt No. Permit No. Issuance Date Mailed Delivered <br /> s <br /> - APPLICANT—RETURN ALL COPIES 70: ENVIRONMENTAL HEALTH PERMITlSERYICES 1BD1 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,GA 95201 <br /> � y <br />