Laserfiche WebLink
Applications Will Be Processed When submitted Properly Complet <br /> U <br /> APPLICATION �UL 14 19$0 <br /> (For Non-Transferable, Revocable, <br /> ' FOR OFFICE USE-. � � -� - <br /> Suspendable PUMP&WELL <br /> ENVIRONMENTAL HEALTH PEFSAIR JOAQUIN LOCAL <br /> QUALITY HEALTH DISTRICT <br /> (COMPLETE�IIN TRIPLICATE) ��[� _..-+'z'Ec (�- ;.- <br /> toconstructand/orinstalltheworkhereindescribed.Thisapplicationis <br /> Application isherebymade tothe San Joaquin Local HealthDistrictoa ermit <br /> made in compliance with San Joaquin Count Ordinance Not 862 and the rules and regulations of the SarV <br /> d 4Vaquiia Local Health District. <br /> e� 1` Sc C_ City/Town N <br /> E=xact Site Address 5^ <br /> 1 GI <br /> Phone % <br /> w 1 <br /> .,-� <br /> iS <br /> Owner's Name 3 W ^se%, City <br /> Address U r <br /> Rt _ .�`"�12� Business Phone <br /> Contractor's Name i Li nse#� <br /> me c Phone 026�S i�C? SI7 fol <br /> Contractor's Address �s�'�_ No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD. <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION 13 DESTRUCTION�❑ PUMP REPAIR Q <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 1A' <br /> REPLACEMENT❑ <br /> Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank <br /> Cess Dol/Seepage Pit Other <br /> Sewage Disposal Field p <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL J <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> f ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> .�.IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION <br /> 11 ROTARY Type of Grout <br /> I ❑ OTHER <br /> Other Information <br /> ❑ DISPOSAL <br /> I 13 GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump rY ''�0 H.P. } <br /> ; <br /> i13State Work Done <br /> PUMP REPLACEMENT: <br /> PUMP'REPAIR: ❑ State Work Done <br /> Well Diameter <br /> DESTRUCTION OF WELL: Approximate Depth <br /> Describe Material and Procedure ,• �� <br /> r I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County t <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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grou�lnspection prior to grouting and a final in tion. <br /> Title: ! � in - Date: <br /> F Signed X P "' <br /> (Draw —!W- <br /> Plat Plan on Reverse Si e) <br /> F DEPA TMENT USE ONLY <br /> ! PHASE I a Date <br /> i <br /> Application Accepted By <br /> Additional Comments: I Final Inspectio <br /> Phase Ii Grout Inspection <br /> fl,,,� <br /> Inspection By <br /> Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE El EACH ❑ January 1 &R cel d By January 31 E] July 1 &Received <br /> EMITu1y 31 <br /> ON BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> EXPLANATI <br /> BASE DATE DATE REMITTED AMOUNT <br /> Z ^` <br /> FEE � e�` <br /> LESS <br /> PRORATION <br /> I PLUS <br /> PENALTY <br /> OTHER <br /> OTHER ` <br /> Received by <br /> Date Receipt No. Perms o.,1 Issuance Pate Mailed D livered A <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.evn 2009 CCKTON,CA 95201 <br />