80-719 - Laserfiche WebLink

Home Browse Search

Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable,Suspendable) t ` ~ PUMP& WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is made in compliance with S�Jpaquin County Ordinance No. 1862 and the rules and regulations of the San Jo uin LocalHealth District. Exact Site Address City/Town Owner's Name Phone r Address f City Contractor's Name i License#� Business Phone Contractor's Address Errlergency Phone a + Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes >e No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDIT•IO N 13DESTRUCTION❑ WELL CHLORINATION El WELL ABANDONMENT ❑ OTHER 13 PUMP INSTALLATION El PUMP REPAIR❑ REPLACEMENT) r ` DISTANCE TO NEAREST: Septic Tank.. Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL y❑ INDUSTRIAL © CABLE TOOL Dia. of Well Excavation jam+ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing Qf ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout - ❑ DISPOSAL ❑ OTHER Other Information* �y ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump / H p PUMP REPLACEMENT: State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure Q J � I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County I ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. ; Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit - is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." R Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this permit is issued, I shall employ persons subject to workman's compensation laws of California." I will c r a Grout inspdo prior to grouting and a final in�Side) Signed X / Title: Date:an o OR D ARTMENT SE ONLY PHASE I i Application Accepted By - Date jo Additional Comments: Phase II Grout Inspection Phase III Final Inspection 4 Inspection By Date Inspection By I Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ Januar 1 &Received B Januar 31 ` ,_. Y y y ❑ Ju 1 &Received By July 31 � BILLING REMITTANCE $ REMIT BASE EXPLAN TION PATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT i FEE LESS PRORATION PLUS PENALTY OTHER + OTHER } 1 Received by -Date Receipt No. Permit No. Issuance� Date - Mailed Delivered - " APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL-HEALTH PERMITISERVICES , - 1601 E.HAZELTON AVE.,P.O.Box 2009 ,STOCKTON,CA 95201 11 - - - - .