Laserfiche WebLink
- _ <br /> Applications Will Be Processed-When Submitted Properly Completed. Be Sur Ine ���a°��r�• <br /> FQR OFFIi USE: APPLICATION <br /> �enb(For Non-TransferableRevocableu ) -z r Limp&WELL <br /> ENVIRONMENTA RMIT Sao f <br /> (COMPLETE IN TRIPLICATE) �,y� <br /> WATER Q y� 411 <br /> Y <br /> Application ishereby madetothe San Joaquin Local Health Districtforapermit strl�lpttt�d/orinstalltF� ereindescribed.Thisapplicationis <br /> made in compliance with San oaquin County Ordinance No. 11362 and the rules and regulati� JI:1� quin Local Health District. <br /> Exact Site Address <br /> Nlill Phone 6 3_ S D <br /> Owner's Name <br /> City <br /> Address -��� _7S <br /> License#&?,31— Business Phone <br /> Contractor's Name <br /> Contractor's Address �1� —�2 7 _ Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> No I <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 0' S <br /> WELL CHLORINATION ❑ WELL ABANDONMENT [1 OTHER 11 PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ i <br /> Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines C? <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ NDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE 13 DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H P' <br /> PUMP REPLACEMENT: 11 state Work Done <br /> PUMP REPAIR: estate Work Done y <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that 1 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, 1 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, I shall employ persons subject to workman's compensation laws of California." <br /> I I VAI call for a Grout inspection prior to grouting and a final inspection. <br /> Signed X <br /> Title: Date: - <br /> (Draw Plot Plan on Reverse Sid <br /> f FOR D PARTMENT USE ONLY <br /> PHASE I �a <br /> Application Accepted By <br /> Additional Comments:Phase 11 Grout Inspection ha�fII Fi a pec,Date <br /> on <br /> Inspection By (-Date a l! <br /> 1{ Inspection By Dater <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 12"PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveRdEBy July 31 <br /> I BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> { PLUS <br /> PENALTY <br /> F' <br /> OTHER <br /> OTHER <br /> Received by <br /> Date- Receipt No. Permit No. Issuance ate Mailed Delivered <br /> t 1601 E.'HAZELTON AVE..P.O.-Box 2009 STOCKTON,CA 9520 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />