Laserfiche WebLink
Applications WIII Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION 4 <br /> (For Non-Transferable, Revocable, Suspendable) <br /> 1 <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby.Madetto 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 Ordinance No. 1862 and the rules an regulations of the San Joaquin Local Health istricE, <br /> Exact Site Address 7 e �� Y 6 ity/Town f "I/ <br /> Owner's Name Phone 2 <br /> Address Cityot <br /> Contractor's Name l License# f Business Phone -� <br /> Contractor's Address a? ergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHO? Yes X — No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field &V Cesspool/Seepage Pit Other <br /> Property Line4 Private Domestic Well Public Domestic Well <br /> INTENDED USE �1 TYPE OF WELL /I <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing i <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of GroutFV <br /> ❑ DISPOSAL IOTHER Other Information l 5 <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 /> DESTRUCTION OF WELL: Well Diameterit Approxinjate e <br /> Describe Material and Procedure ® ov ✓of G�t'i <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 /> Home owner 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 /> 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 /> QE Q`7 <br /> i <br /> I ;W111all for a Grout Inspects prior to grouting nd a final inspection. <br /> • l <br /> Signed X Title: Date: <br /> f (Draw PI Pian on Reverse S e) <br /> I FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted y Date <br /> Additional Comment <br /> P e rout inspection �Lr Phase/III Final Inspection <br /> Inspection By Date Inspection By M7 Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Juiy 1 &Received By July 31 <br /> REMIT I <br /> BASE 'EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> 3 <br /> I LESS <br /> PRORATION I <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> r; - <br /> R"eivetl,by. e_.�., - Oat -., _ ,- Receipt No. --,Permit Noy Issuance Date- Mailed Delivered _ <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />