Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be SureTosign TneAppllca�2 6`2— <br /> FOR OFFICE USE, !! APPLICATION <br /> ' QFl!/[ �L11tiw� (F'rNNOn-Translerable, Revocable,Suspendable) WELL'PUMP& <br /> 0. 1/Wilerl//��� 5�ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> `0 <br /> Application is hereby madetotheSan Joaquin Local Health Districtfora permitto construct and/or install thework herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San ,j,gaqui�l Local Health District. <br /> Exact Site Address Z L .1S City/Town so N7 <br /> Owner's Name t `t L Phone 7T_ 7 <br /> AddressCity S <br /> Contractor's Name C0 V& L License#'?71 L!�{ Business Phone — I <br /> Contractor's Address' s Emergency Phone j <br /> Is Certificate of Workman's Compensation Insura a on Fil ith SJLHD? Yes No i f <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN El RECONDITION E] DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ J <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other— <br /> Property Line'2�7 Private Domestic Welrt"z'�' Public Domestic Well <br /> INTENDED USE <br /> ' TYPE OF WELL !/ <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation I <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing CL ; <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal �T C <br /> ro <br /> CATHODIC PROTECTION X 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: ❑ State Work Done <br /> I 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 si re certifies the following:"I certify that in the performance of the work for which this <br /> per 't is 'Issued, I shall employ persv su ect to workman's compensation laws of California." <br /> will call to i I Ilion routing and a final inspection. <br /> It <br /> �z Title: Date: <br /> Signed X <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - 7-3 <br /> Application Accepted By Date <br /> Additional Comments: U <br /> Iia l Phase II Grout Inspection Phase 111 F'naI Inspection <br /> 7IDate <br /> Inspection By Date Inspection By <br /> 2S�S�Z ��me sfi�`r+ �smt� hr o�.tpn 5�ea lr 7r1u/tkl, <br /> Fee fS Due: El ANNUALLY PER UNIT El PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASEp EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> /tiiy <br /> PLUS ^ R <br /> PENALTY <br /> l . r Gfo < s rr�vG <br /> +[ OTHER <br /> OTHER / <br /> Receipt No. Permit No. Issuc Dat Mailed Delivered <br /> Received by�s Date P <br /> ' ApPL1CANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> e <br />