Laserfiche WebLink
i A i4J1L %fit0 P�erNon_Transierable, <br /> hen Submitted Properly Completed.Be Sure To Sign The Apptication. <br /> FOR OFFICE15 APPLICATION <br /> Revocable, Suspendable) PUMP&WELL <br /> OCT 0 i�8, <br /> ENVIRONMENTAL HEALTH PERMIT <br /> I <br /> (COMPLETE IN TRI TAQUfN LOCAL WATER QUALITY <br /> Application <br /> mLbT6hnDQgTilRkGTalHealth Districtforapermit toconstruct and/or install the work herein described.This application is <br /> made in cfan Joaquin County OrdinanceeNNo. 662 and the rules and regulattiio�n, of Sa Joaquin Lo al Health District. ' <br /> W&O 74-AV <br /> Exact Site <br /> Owner's Name Phone <br /> Address .24 City— <br /> Contractor's <br /> ity Contractor's Name License# Business Phone <br /> Contractor's AddressEmergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X — No --� <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ tS' <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ � <br /> REPLACEMENT❑ 1 <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field 7,5-/ Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL f' Jf <br /> ❑ 11 <br /> ^� INDUSTRIAL CABLE TOOL Dia. of Well Excavation <br /> { <br /> J`� DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information I�YICI <br /> ❑ GEOPHYSICAL Surf'ce Seal installed By: <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 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." r <br /> I will all for a Grout Inspe n prior to grouting and a fi al inspection. <br /> Signed X Title: Date: 16 Ap <br /> (Draw lot Plan on a erse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By 00, Date `Z3 <br /> Additional Comments: <br /> a e II Grout Inspectionc� i ase III Final Inspection SL <br /> �� "�d � Ins y <br /> Inspection By Date pection B Date <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> ti REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> ! y� DATE DATE REMITTED AMOUNT <br /> FEE <br /> 14 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY v <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. issuance Date Mai ed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />