Laserfiche WebLink
Applic W 9e'Processed When Submitted Properlycompietea. <br /> APPLICATION J <br /> OR OFFICE USE: Non-Transferable, Revocable, Suspendable) <br /> . PUMP&WELL <br /> HEA�.TH ENVIRONMENTAL HEALTH PERMIT ,- <br /> r WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> nLocalHealthDistrictforapermittoconstructand/orinstafltheworkhereindescribed.Thisapplicationis <br /> Application is hereby made to the San Joaqui <br /> � <br /> made in compliance with San Joaqu n CouInky O dinance N . 1862 and the rul a d regulations of the San J aquin Local Health District. <br /> City/Town 1 <br /> Exact Site Address r <br /> Phone Lit Ss • <br /> j Owner's Name -7h�-7-1 <br /> City <br /> Address <br /> Contractor's Name License# -1�S`� Business Phone <br /> r / .. Emergency Phone <br /> Contractor's Address _ �—.� } No <br /> Is Certificate of Workman's Compensation Insurance on Fife With SJLHD? Yes _ <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ // � Pit Privy e�— <br /> DISTANCE TO NEAREST: Septic lank tD C7 ®ewer Lines - <br /> Q Cesspool/Seepage Pit �� Other <br /> ,.Sewage Disposal Field - - <br /> Property Line *-� Public Domestic Well Private Domestic Well � <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL 13 CABLE TOOL Dia. of Well Excavation of <br /> r <br /> DOMESTIC/PRIVATE <br /> 13DRILLED Dia. of Well Casing s <br /> I DOMESTIC/PUBLIC <br /> ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 'N <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> 13 OTHER Other Information <br /> 11,DISPOSAL t" <br /> 13 GEOPHYSICAL <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> H.P. - <br /> Type of Pump <br /> s PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: <br /> Well Diameter Approximate Depth <br /> i Describe Material and Procedure <br /> '1 <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 signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is.issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will c .yr a Gr Lit lnsp ct' n prior to grouting and a final Inspection. <br /> - ate: ,r��'�1_L•_— <br /> Signed X Title: <br /> raw Plot Plan on Reverse Side) <br /> FOR D ARTME T USE ONLY <br /> PHASE I Q Date <br /> F Application Accepted By <br /> Additional Comments: <br /> Phase !II Final Inspection <br /> Phase 11 Grout Inspection pate <br /> Inspection By <br /> Date inspection By <br /> F 1.i <br /> Fee Is Due: ❑ ANNUALLY ❑-PER UNIT /ffPER SITE ❑ EACH ❑ January 1 &Received By January 31 El Joy 1 R ReceiveRd MITuly 31 <br /> i f BILLING REMITTANCE $ A LINT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE �p <br /> LESS 1 <br /> PRORATION - <br /> i 3 <br /> PLUS <br /> PENALTY <br /> OTHER �' - <br /> t � <br /> OTHER 0 1 <br /> Received 6y <br /> Date Receipt No, Permit No Issuance Date Mailed Delivered <br /> APPLICANT 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> —RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />