Laserfiche WebLink
`.l'Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign rThe-Apf <br /> piicatiori. <br /> APPLICATION <br /> FOR OFFICE USE: :_f ; a <br /> xj (For Non-Transierable, Revocable,Suspendable) <br /> PUMP&WEA„LL <br /> r . <br /> ENVIRONMENTAL HEALTH PERMITy .,. <br /> rti (COMPLETE IN TRIPLICATE) IC�� __'7 � 1: tij E 1C WATER QUALITY ;,�0 ' <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 /> i made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of'the San do uT Local Health District. <br /> 1 Exact Site Address 's s �c�-tk City/Town <br /> _ <br /> Owner's Name �.h i _ Phone <br /> Address * City <br /> Contractor's Name License# _1'2 7 71 L Business'Phone� p © <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File W SJLHD? Yes t.l__� No <br /> 4 `+ <br /> k.. TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLA lON ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> g DISTANCE TO NEAREST: Septic Tank f Sewer Lines "f Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line1.. Private Domestic Well` <br /> Public Domestic Well <br /> INTENDED USE ,.�,��T.YPE OF WELL'°f <br /> ❑ INDUSTRIAL I!d'C4BLE TOOL [ Dia. of Well Excavation <br /> rr "* <br /> ❑ DOMESTIC/PRIVATE C3 DRILLED ) Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC x,410 DRIVEN F _ � Gauge of Casing © ' <br /> 'IRRIGATION 1:1GRAVEL',PACK � Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY '` < I; Type of Grout �Y <br /> 11 DISPOSAL ❑ OTHER ., Other-Information . <br /> 13 GEOPHYSICAL - Surface Seal Installed By: { <br /> PUMP INSTALLATION: Contractor Y" <br /> iTYpe of Pump + � .�� H.P. <br /> t PUMP REPLACEMENT: t❑ State V+ ork bone <br /> PUMP REPAIR: ❑ State Work Done'f F r <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 + <br /> f 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 certiTy 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, hshali employ persons subject to workman's compensation laws of California." R <br /> i <br /> I will c for a Grout Insp n p ion to grouting and a final inspecti n. _ - <br /> r <br /> ` Signed XZt) Titie: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> l R <br /> PHASE I /} _ 2cn4 <br /> Application Accepted By_ -��/"// _ - Date ! �' <br /> Additional Comments: <br /> 4 <br /> Phase II Grout Inspection Phase Ili Final Inspe tion f <br /> Inspection By I Date Inspection By�� r ' Z Date <br /> � I <br /> Fee Is Due: 11ANNUAlLY— ❑ PER UNIT ❑ PER SITE ❑EACH ❑ January 1 &Received By January 31 July 1 &Received By July 31 <br /> IT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED . <br /> DATE DATE REMITTED AMOUNT <br /> FEE t <br /> LESS <br /> PRORATION <br /> PLUS <br /> I PENALTY <br /> OTHER <br /> OTHER <br /> ` Received by Date Receipt No. Permit No. Issuance Datb Mailed Delivered '+ <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON;CA 96201 <br />