Laserfiche WebLink
_ _ <br /> Applications Will Be,Processed When Submitted roper y o <br /> FOR OFFICE USE: (} APPLICATION <br /> Ccmetft4af (For Non-Transferable, Revocable,Suspendable) pliMp&WELL <br /> ENVIRONMENTAL HEALTH PERMIT ' <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Appl ication is hereby made to the San Joaquin Local Health District fora permit to construct and- install thework herein described.This application Is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joa uin Lo al Health Distri <br /> City/Town <br /> Exact Site Address <br /> o <br /> i Phone <br /> Owner's Name <br /> City_��r711O <br /> Address <br /> /tea l <br /> Contractor's Name <br /> License#1_F3—� Business Phone L <br /> ., � Emergency Phone <br /> Contractor's Address o No oz} <br /> Is Certificate of Workman's Compensation insurance on File Wit SJLHD? Yes - <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 13 OTHER ❑ PUMP IN <br /> 13 PUMP REPAIR® - <br /> REPLACEMENT i Pit Priv <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines y <br /> Sewage Disposal Field rCesspool/Seepage Pit Other 1 <br /> I Public Domestic Well J <br /> Property Line Private Domestic Well t <br /> INTENDED USE TYPE OF WELL <br /> 11 INDUSTRIAL 13 CABLE TOOL Dia. of Well Excavation <br /> 1 <br /> 19 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC <br /> ❑ DRIVEN Gauge of Casing t <br /> ❑ IRRIGATION <br /> C3GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL <br /> 13 OTHER Other Information <br /> Surface Seal Installed By: <br /> ❑ GEOPHYSICAL <br /> 0 <br /> Contractor ` <br /> (PUMP INSTALLATION: H.P. <br /> It Type of Pump <br /> ❑ state Work Done <br /> PUMP REPLACEMENT: s <br /> PUMP REPAIR: ® State Work Done <br /> RPea DESTRUCTION OF WELL: <br /> Well Diameter Approximate Depth <br /> Describe Material and Procedure s <br /> I hereby certify that I have prepared thiisaptaf the San Joaqu n Locaion and that the work l lHealth District.l be done in accordance <br /> cordance with San Joaquin County <br /> ordinances, state laws, andregulations <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work far 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 /> ect to workman's compensationlawsof California." <br /> permit is issued, I shall employ persons subj <br /> I will call for a Grout Inspection prior to gro a a In I i ecto <br /> Date: , <br /> 4f e <br /> i le: <br /> Signed X <br /> (D Piot Plan on Reverse Side) <br /> " FOR DEPARTMENT USE ONLY <br /> PHASE Date Application Accepted By 1 t IVW <br /> FAdditional Comments: E ha Ill F' al Inspection <br /> I Phase 11 Grout Inspection pate <br /> Inspection By <br /> Date Inspection B <br /> t ❑ ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 July 1 &Receiv d'By July 31 <br /> Fee IS Due: [I ANNUALLY PER UNIT <br /> F BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> " BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> r i <br /> lam _ <br /> � FEE <br /> I LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> f' <br /> OTHER <br /> - In <br /> Date t Receipt No. Permit No. Iss ance ate Mailed Delivered <br /> _ Received by y <br /> —RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES v 1601 E.HAZELTON AVE.,P.O.Boa 2609 STOCKTON,CA 45201 <br /> APPLICANT <br />