Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTheApplication. <br /> FOR OFFICE USE: APPLICATION 3d <br /> (For Non-Transferable, Revocable,Suspendable) PUMA&WELL *1� <br /> ENVIRONMENTAL HEALTH PERMIT 'Y <br /> (COMPLETE IN TRIPLICATE *c.r/4-C-Gi�f+E*J4 wt-1 QUALITY <br /> i Application is herebymadetotheSanJoaquinLocalHealthDi,,tri tforapermittoconstructand/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address � City/Town 4C—S <br /> Owner's Name 4&Lec Phone G38 — 3 S 3 <br /> Address City - <br /> Contractor's Name License# Obs/ Business Phone <br /> Contractor's Address Emergency Phone S I"457 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes NI/ No <br /> TYPE OF WORK (CHECK): NEW WELL® DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION JR PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 4x3170 Sewer Lines h6/7E " Pit Privy 4 _ <br /> Sewage Disposal Field "0 eg Cesspool/Seepage Pit /1"C= Other <br /> Property Line Private Domestic Well n&O— Public Domestic Well /9ion <br /> INTENDED USE _ TYPE OF WELL <br /> 13 INDUSTRIAL i❑ CABLE TOOL Dia. of Well Excavation . <br /> ' ❑ DOMESTIC/PRIVATE r ❑ DRILLED Dia. of Well Casing <br /> ® DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing2- <br /> I 8 � <br /> ❑ IRRIGATION 0 GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> . C.0 n e <br /> ❑ DISPOSAL ❑ OTHER Other Information _ <br /> ❑ GEOPHYSICAL Surface Seal std By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth S <br /> Describe Material and Procedure �1 <br /> I hereby certify that I have prepared this application and that the work will be dorie-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 /> I permit is issued, I shall a loy ersons subject to workman's compensation laws of California." <br /> ill call for a G ut I p 1 p 'or t grouting and a final inspection. <br /> 1 Signed X y Title: • Date: Z <br /> (Draw Plot Plan on Reverse Side) <br /> FOR EPARTMENT USE ONLY <br /> I <br /> Application Accepted By Q� Date <br /> Additional Comments: <br /> 1�,et/ Ph 11 Grout nspection Z7/2 ase II Final Inspection <br /> t <br /> Inspection By�� Date Inspection B 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 BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> 3 FEE Agi_ <br /> LESS <br /> PRORATION .. <br /> PLUS <br /> PENALTY <br /> OTHER <br /> ( OTHER <br /> _N Ja 2�17 )I V7D t7i!I Fl-T 1 4-751 <br /> Received by' Date Receipt No. Permit No. Issuance Date Maiied Delivered <br /> STOCKTON,CA 85201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O:Box 2005 - <br />