Laserfiche WebLink
ApplicationsWill Be Processed When Submitted Property Completed. Be Su /� Sign The Application. Y <br /> FOR OFFICE USE: APPLICATION �f 1J (�,Jf <br /> (For Non-Transferable, Revocable, Suspendabl <br /> PUM <br /> (COMPLETE IN TRIPLICATE) <br /> ENVIRONMENTAL ERTER Q AL TYTH PERMIT JAN �9 193 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/orinstaalt wJQ�ler escribed.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the �4Yu�' <br /> Exact Siterddrese r��// �y� T,gy� /max � I t!Oistrict. <br /> _ City/Town <br /> Owner's Name 75tItIll''� c=� <br /> Address Phone <br /> } �S`!�. �J� CalVG/i�5i _ City -Se�dc�lts7� <br /> Contractor's Name L��,Q��,��� ,a License#, OLS Business Phone <br /> Contractor's Address l 9d 3 Emergency Phone +mss/���'YS ] • �4/Z <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 1'e No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR& r <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 ❑ 9 <br /> DRILLED Dia. of Well Casing <br /> firDOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information D <br /> ❑ GEOPHYSICAL Surface Seal Installed By: # <br /> PUMP INSTALLATION: Contractor i <br /> -_ ii <br /> Type of Pump H P <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: <State Work Done <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 /> Home owner 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." i <br /> Contractor's hiring or sub-contracting signature certifies the following:1 certify that in the performance of the work forwhich this �40 <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> )1W=' O'00ra Grou tion prior to grouting and a final inspection. <br /> Signed X Title: . ,(/!G� <br /> {Draw Plot Plan on Reverse Side} <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> y Application Accepted By -2-- Date <br /> Additional Comments: <br /> Phase II Grout Inspection <br /> h 111 Final Inspection <br /> Inspection By ate Inspection By Date <br /> Fee IS Due; ❑ ANNUALLY ❑ PER UNIT ❑ PER 517E ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &R eived By July 31 <br /> all-LING REMITTANCE $ REMIT <br /> BASE EXPLANATION - AMOUNT DUE CHECKED' 1 <br /> DATE DATE REMITTED y <br /> AMOUNT <br /> FEE [ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> F <br /> OTHER J <br /> OTHER - <br /> i <br /> 1 �S. 7_�_S1 <br /> Received by Date. Receipt No. Permit No. 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 r <br />