Laserfiche WebLink
ppncauonswill BeProcessedWhen Submitted Properly Completed. 86 eS�)W9,-�he QIic�) - Ub <br /> FOR OFFICE USE: APPLICATION L� 'f <br /> (For Non-Transferable, Revocable,Suspendable) AUG 3 1981 V + <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY �'�� '''"0''j'�' LOCAL. <br /> Application is hereby made to the San Joaquin Local Health Districtforapermit toconstructand/orinstalllltheworkhereindessc ed.This application is <br /> made in compliance withn Joa uin Gounty r mance No. 1862 and the Illlu es and regulations of the San Jo uin Local Health District. <br /> Exact Site Address <br /> �s <br /> Owner's Name it—Q,11,?- <br /> City/Town <br /> Address Phone <br /> Contractor's Name 7 City 2y G] <br /> Contractor's Address icense#�`�Business Phone_ <br /> Is Certificate of Workman's Compensation_Ins} ance on File With SJLHpmergency Phone <br /> TYPE OF WORK (CHECK): NEW WELT Yes Na r <br /> WELL CHLORINATION ❑ 7`-� DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ r�� <br /> WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ v , <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank <br /> Sewer Lines Pit Privy <br /> Sewage Disposal f=ield ; <br /> Cesspool/Seepage Pit <br /> INTENDED USE Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOLDia. of <br /> DOMESTIC/PRIVATE Well Excavation <br /> ❑ DRILLED Dia. of Well Casing <br /> '?�DOMESTIC/PUBLIC ❑ DRIVEN <br /> ❑ IRRIGATION Gauge of Casing fi <br /> ❑ CATHODIC PROTECTIONRAVEL PACK Depth of GroutSeal <br /> ElDISPO IJP►nOTARY Type of Grout <br /> SAL ❑ OTHER A <br /> ❑ GEOPHYSICAL Other Information <br /> PUMP INSTALLATION: Surface Seal Installed By: : <br /> Contractor <br /> Type of Pump H P <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR' ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 thework for which this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation taws 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 wit for a Grout nspection prior to grouting and a final Inspection. <br /> Signed X � <br /> Title: Date: l <br /> {Draw Plot Plan on Reverse Side) <br /> PHASEi FOR DEPARTMENT USE ONLY <br /> Application Accepted By <br /> Additional Comments: ! 1 �eC�, Date <br /> Phase 11 Grout Inspection <br /> Inspection By Phase III Final Inspection <br /> Date Inspection By <br /> Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UN)T ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE L1 ` AMOUNT <br /> I DO <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. ermit No3 <br /> Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH pERMITPSERVICES fs uance Date Mailetl <br /> 7601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 35201 <br />