Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with SanJo/auin/County Ordinance/N 1862 a d the rules and regulations of the San Joaqui Local Health District. <br /> Exact Site Address .2 6 �h _ / 4n/ � City/Town 9!g:-2. <br /> Owner's NamePhon e216 X <br /> Address City <br /> Contractor's Name 2a License Business Phone �y �/G <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes� No <br /> NEW WELL <br /> TYPE OF WORK (CHECK): NDEEPEN 11RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ LWE L ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ I <br /> DISTANCE TO NEAREST: Septic Tank �*-3 4 Sewer Lines (}iV -F Pit Privy <br /> Sewage Disposal Field &.o Cesspool/Seepage Pit Other <br /> Property Line//T Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation_��� <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 7 __ <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing _ ""novr b,*L z f� <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal U � <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information A A-c/� ca Ik LO N <br /> ❑ GEOPHYSICAL Surface Seal Installed By: 16g)AIErr <br /> PUMP INSTALLATION: 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 Approximate Depth <br /> Describe Material and Procedure <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 performanceof thework forwhich 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 forwhich this <br /> permit is issued, I shall employ per s ns subject to workman's compensation laws of California." <br /> I will call for a Gr ul In echo r to grouting and a final inspection. <br /> _ iG <br /> Signed X Title: &6r AL Date: itc�6 <br /> (Draw Plot Plan on Revers ide) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I airs <br /> Application Accepted By Vy Date 3 A-M0 <br /> Additional Comments: I <br /> Phase II Grout Inspection h Ill Final Inspection+ <br /> Inspection By Date Inspection By Date S <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Ir <br /> Received by Date Receipt No. Permit No. 11suance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />