81-315 - Laserfiche WebLink

Home Browse Search

S r Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. OFFICE USE: APPLICATION (For Non-Transferable, Revocable, Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) _ ATER QUALITY Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made in compliance with,San Joaquin County Ordinance No. 1862 and the rules and regula�o s f tpp San Joaquin Local Health District. I Exact Site'Address �1 "� City own Owner's Name &` "r'"" Phone p Address Citya Contractor's Name License#/4- -- Business Phone_ �^- Contractor's Address f Emergency Phone - 4e(� Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No. TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ fi -WEAL- CHLORINATION ❑ - WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ZI PUMP REPAIR❑ REPLACEMENT❑ ff DISTANCE TO NEAREST: Septic Tank �O SeweLines S Pit Privy N Q N Sewage Disposal Field 'gaO AV Cesspool/Seepage Pit 41 a Other Property Line Private Domestic Well—/-12)_./ Public Domestic Well INTENDED USE TYPE OF WELL fj ❑ INDUSTRIAL E] CABLE CABLE TOOL Dia. of Well Excavation (' ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 80 © DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing JD IRRIGATION ❑ GRAVEL PACK Depth of Grout Sear ! ._.. El CATHODIC PROTECTION 9 ROTARY Type of Grout 4. ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL PSurface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H.P. �wACounty PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure I hereby certify that I have prepared this application and that the work will be done i'ri accordance with San ordinances, stale laws, and rules and regulations of the San Joaquin Local Health District. Homeowner or licensed agent's signature certifies the following."I certify that in the performance of the work for which this permit j manner as to become subject is issued, I shall not employ any person in such1ect to workman's.compen sation laws of California.' Contractor's hiring or sub-contracting signature certifies the fallowing:"l certify that in the performance of the work forwhich this permit is issued, I shall employ persons subject to workman's compensation laws of'California." I will for Grout lnspe 'on prior to grouting and a final insp tion. p Signed X Title: Date: - i (Draw Pot an on Reverse de) FOR DEPARTMENT USE ONLY PHASEI Application Accepted By Date Additional Comments: Phase II Grout Inspection ha a III Final Inspection Inspection By Date Inspection B Date Fee Is'Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Juiy 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE -� LESS PRORATION PLUS PENALTY OTHER - i [ OTHER + Received by, Date Receipt No. Per it No. I uance a Mailed eOered - k APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL'HEALTH PERMIT/SERVICES^— 1601 E.HAZELTON-AVE.;P.O.Box 2009 STOCKTON,CA 95