Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed.Ce,Sur o Igo he Application. <br /> _ FOR OFFICE USE: <br /> tI APPLICATION', <br /> (Foi Non-Transferable, Revoct>cS�s�- <br /> �gaO <br /> 11Ev1; <br /> PUMP&WELLENVIRONMENTAL PER <br /> (COMPLETE IN TRIPLICATE) WATER �AO� <br /> Application is hereby made to the San Joaquin Local Health District for a per mittoconstruct and/or i� 6the.Vv herein described.This application is <br /> made in compliance wit cSiaJn4paquin unt Ord' ance_bJp. 1862 the rules and rmpla�q��"If,th quin Local, alth is t. <br /> Exact Site Address _ 7 ��`+ CMTown <br /> Lj[ Cti <br /> Owner's Na� / '���U S d Jl <br /> Phone <br /> Address City <br /> Contractor's Name ew A I / 37 � �-f-r <br /> License# usiness Phone <br /> Contractor's Address �T Zl I'li-I Emergency Phone �� <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL M-' DEEPEN❑ RECONDITION❑ DESTRUCTION❑ } <br /> WELL CHLORINATION ❑ WELL ABANDONMENT !❑ OTHER ❑ PUMP INSTALLATION Ga'�' PUMP REPAIR❑ <br /> REPLACEMENT❑ / <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines 4 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 �r <br /> ❑ INDUSTRIAL ❑ CABLE TOOL.. . Dia. of Well Excavation..... <br /> MIO'DOMESTIC/PRIVATE ❑ DRILLED Oia. of Well CasingAl <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION EKOTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surfaceal In t Iled <br /> PUMP INSTALLATION: Contractor 's y <br /> Type of Pump H.P, ; <br /> i <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> µ <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 /> 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 n mploy any person in such manner as to become subject to workman's compensation laws of California." <br /> I Contractor's ri g or sub-cont signature certifies the following:"I cehat in the performance of the work forwhich this <br />` per Is 15 a sh I empl y perso subject to workman's compensa laws of California." <br /> i I will c o Inspecti prior o grouting a d a final inspectio . <br /> Signed X Title: Date: >� <br /> (Draw Plot Plan on Reverse Side) {{� <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By ©4;1 Date <br /> 4�� <br /> Additional Comments: <br /> ase A Grout Inspection nal Inspection - <br /> Inspection�UALLY <br /> Date Inspection By Date <br /> Fee is Due: ❑ ❑ RFR.UNIT ❑ PER SITE ❑ EACH Cl January 1 & eceived By January 31 ❑ July 1 &Received By July 31 <br />` REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT i <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No Iss ante D to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952 <br />