Laserfiche WebLink
_V � .— <br /> Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. �) <br /> LFOROF�ICE use: APPLICATION(For Non-Transferable,Aevocabie,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordira ce No.1862 and t rules and regulations of the uin Local Health District. <br /> Exact Site Address_�0-3 tDO[a - City/Tow r <br /> Phone <br /> Owner's Name r <br /> AddressCity <br /> I Contractor's Nam <br /> Eee420(o �S Business Phone <br /> Contractor's Address ^-� m �ency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No G <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ - RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION M—PUMP REPAIR❑ <br /> REPLACEMENT❑ } <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Filld / --rL— _ Cesspool/Seepage Pit Other <br /> Property,Line 1.5 Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL ! �� <br /> ❑ IN�TRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> [SDOMESTIC/PRIVATE T] DRILLED Dia. of Well Casing CO <br /> ❑ DOMESTIC/PUBLIC <br /> ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION 0GRAVEL PACK Depth of Grout Seal <br /> ❑ �,,CATHODIC PROTECTION ROTARY Type of Grout <br /> p ❑ DISPOSAL ❑ OTHER Other Information <br /> f ❑ GEOPHYSICAL , Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor t <br /> Type of Pump H.P. <br /> It <br /> 13State Work Done PUMP REPLACEMENT: W <br /> PUMP REPAIR: 11State Work Done a <br /> Approximate Depth d <br /> DESTRUCTION OF WELL: 'Well Diameter - _ <br /> i Describe Material and Procedure M <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 tracting signature certlties the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall a ploy" ersons subject to workman's compensation laws of California." I <br /> will call for a G ou s tion rl r to grouting and a final inspection. f <br /> F Signed X Title: �` • Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY Q <br /> PHASE 1 (4+r�'✓ -l'�� 1 <br /> Date <br /> Ion Accepted By <br /> Additional Comments: <br /> Phase III Final Inspection <br /> a e II Grout pection <br /> InsDate l� <br /> Inspection By <br /> Date <br /> Inspection By <br /> Fee Is Due: EI ANNUALLY ❑ PER UNIT ❑ PER SITE El ❑ January 8 Received By January 31 C] July 1 &-Received <br /> REMlTJuly 31 <br /> BASE EXPLANATION - BILLING REMITTANCE - $ AMOUNT DUE - CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS �'J� ,, G—Lf4'I <br /> PRORATION <br /> PLUS N 'l.�►f4r fi/J �IW� <br /> 0A1 <br /> OTHER <br /> t l!" CCl-vt't'✓ F <br /> PENALTY <br /> OTHER 10 4 - CI�f Ur.d LrP Y1 <br /> OTHER 1\Ceal C',j9pdv4U6-i• - ,�" Z ✓ .�lL� y} 4�"��.( <br /> f �" . — vn <br /> + ,��•b 7 - H ��� <br /> Received by ate Receipt No. Permit No. _ Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES. 1601 E.HAZELTON AVE.,P.O.Boli 2009 STOCKTON,CA 9520 <br />