Laserfiche WebLink
ApplicationsWill BeProcessed When Submitted ProperlyCompleted. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> �. (For Non-Transferable, Revocable,Suspendable) <br /> PUMP eWEl_L <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE�IN TRIPLICATE) WATER QUALITY 4 <br /> Application is hereby made to the San Joaquin Local Heaith Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and th rules and regulations of the San Joaqul L cat He Ith District. <br /> Exact Site Address 1 � Al 40I)ce S �_ City/Town Q4 <br /> Owner's Name45769 <br /> Phone <br /> Address - City <br /> 7 9 <br /> Contractor's Name Nil g& 'S %ZLicense#3 Business Phone <br /> Contractor's Address C Emergency Phone —:5 H>,: <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 'y^ No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> 1 <br /> DISTANCE TO NEAREST: Septic Tank 1140,#--e- Sewer Lines — Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other " <br /> f f <br /> Property Line loC? Private Domestic Well Public Domestic Well ['3 <br /> . I <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL .CABLE TOOL Dia. of Well Excavation r r <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 —K <br /> © DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: Y\,i- _,, ar s_ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> r s <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth V f1 <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. 1 <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of thework 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 /> k <br /> I 'll all for a Grout Inspection prioLto grouting and a final inspection. <br /> Signed X ` m �f)��,1�� � Title: ./--(Y..Lkt— Date: _ <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY 1 t� <br /> PHASE I <br /> Application Accepted By �• 1 D to <br /> Additional Comments:-' <br /> omments: v� <br /> Phase II Grout lns1pection d Ph a a III final InsPe�tion <br /> Inspection By Date 2—9�� Inspection By w`Date ,2 _! 'z <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Rece+ved By July 31 <br /> BILLING REMITTANCE g REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE (SID, 0113® 4 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. I suance D to I Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />