Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. BOA?�,o Sign The Ap I c Ion.-�""- <br /> FOR OFFICE USE: APPLICATION f V 18 198, �FJJ <br /> `. (For Non-Transferable, Revocable, S694ayle) <br /> PUMP&WELL! <br /> ENVIRONMENTAL HEALTH <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to 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 Cou ty Ordinance No. 1862 and the rules and regulations of the SanJo Lim L Health District, <br /> Exact Site Address City/Townaz <br /> II <br /> Owner's Named Phone <br /> Address 4� - City <br /> Contractor's Name ` - License# 3G? Business Phone <br /> Contractor's Address C Emergency Phone <br /> t Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes _ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER O' PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ f <br /> DISTANCE TO NEAREST: Septic Tank l�4 Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property.L-ine----C;L—Private=Domestic-Welh--^� •�-----Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> t ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> r DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 3� <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing r <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ J <br /> ❑ CATHODIC PROTECTION ElROTARY Type of Grout N <br /> ❑ DISPOSAL, ❑ OTHER Other Information Y <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: PI State Work Done -. ^ <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: WeII Diameter Approximate Depth } <br /> Describe Material and Procedure j <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." <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." 1 <br /> I will c-LalVor a Grout Inspec ' n p . r to groutin and a final inspectio,rpgg <br /> Signed X VOM Title. Date, AF&2f <br /> (Draw Plot Plan on Re erse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date t� { <br /> Additional Comments: 1 <br /> Phase 11 Grout Inspection Phase 111 Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EAGH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMIT <br /> - REMIT CE $ AMOUNT DUE CHECKED <br /> DATE D REMITTED AMOUNT <br /> FEE <br /> E LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER F <br /> OTHER <br /> Received'by„, Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2069 3STOCi(TDN,CA 95201 <br />