Laserfiche WebLink
4, Applications Will Be Processed When S "h"ifted Properly Completed. Be SureToSI Application.— <br /> G FOR OFFICE USE: APPLICATION S 2 p 1979 <br /> (For Non-Transferable, Revocable,Suspendable) HN Jp�Q U' PUMP WELL <br /> TRIPLICATE ENVIRONMWAT R QUALITY NTAL HEALTH PERMIT '4�T/� �'�R0G,q� V <br /> (COMPLETE IN ) 7 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is I <br /> made in compliance with San Joaqu' y Ordinance No. 186 the rules and regulations of the San Joacl in Local Hea4 District. <br /> Exact Site Address `�' City/Town <br /> Owner's Nam el> Id Phone <br /> V. <br /> Address City <br /> Contractor's Name tense# Business Phone_ <br /> 7 <br /> Contractor's Address Emergency Plio� 99-9p- <br /> 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 ❑ PUMP INSTALLATION ❑ UMP FtEPAI <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 O <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED. Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ti <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARYType of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> r <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> UMP R�Al State Work Don 45. <br /> DE T 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 /> 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' " 'ng or sub-contracting signature certifies the following:"I ify that in the performance of the work for which this <br /> pe Led,I all a ploy ersons subject to workman's compe ion laws of California." <br /> wi a ut Ins ction rior to gro ting and a final insZt�� <br /> Signed X Title: Date: �� <br /> (Draw Plot Plan on Reverse Side) <br /> FO EPARTMENT USE ONLY <br /> PHASE I ' / 7 <br /> Application Accepted By Date �l <br /> Additional Comments: '°"'"�' <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION DA7 BILLING E CE $REMITTED AMOUNT DUE CHECKED <br /> IF 00 AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY AA <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date ail d Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,(0-690d. <br /> STOCKTON,CA 95201 <br />