Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> EOR�OFFICE USE: APPLICATION <br /> s <br /> •� "` (For Non-Transferable, Revocable;5uspendable) PUMP&WELL <br /> r- ENVIRONMENTAL HEALTH PERMIT "� <br /> ;. V C-,�Jul t 1 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin ounty Ordinance No 1862 and the rules and regulations of the San J aquin ocal Health District. <br /> Exact Site Address f 042gS! � City/Town <br /> .. h <br /> f ' <br /> Owner's Name 'AZ Phone <br /> Address <br /> Contractor's Name " License ft?, Business Phone <br /> Contractor's Address ii 9T Emergency Phone <br /> -Is Certificate of Workman's Compensation In$urance on File With SJLHD? Yes No on <br /> TYPE OF WORK (CHECK): NEW WELL, DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ <br /> ' WELL CHLORINATION ❑ WELL ABANDONMENT ❑, OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank IAQntSewer Lines -- Pit Privy <br /> Sewage Disposal Field—,ZO,6 ! -I Cesspool/Seepage Pit _ � Other <br /> Property Line JO Private Domestic Well [).. ff 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 3j _ <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing C1"4 s-r161-) eV <br /> ❑ IRRIGATION JZGRAVEL PACK Depth of Grout Seal f <br /> ❑ CATHODIC PROTECTION PLROTARY Type of Grout cx,& a _ <br /> ❑ DISPOSAL ❑ OTHER Other Information "-`- <br /> ❑ GEOPHYSICAL ,t, Surface Seal Installed By: <br /> PUMP INSTALLATION: <br /> Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done R <br /> PUMP REPAIR: ❑ State.Work Done j <br /> DESTRUCTION OF WELL: Well Diameter r 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 /> 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 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 perso subject to workman's compensation laws of California." <br /> 1 Il t r a G u1 In ctio pri to grouting and a final inspection. <br /> Signed X Title: +r Date: d <br /> " {Draw Plat Plan on Rever Side) F <br /> FOR DEPARTMENT USE ONLY r <br /> PHASE r <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phqqe II Grout Inspection Phase II Final Inspection Q' <br /> ' Inspection By D to s Inspection ByDate <br /> Fee Is Due: 11ANNUALLY ElPER UNIT F-1PERSITE 11EACH ElJanuary 1 &Received By!JanuaryJuly 1 &Received By July 31 <br /> xBILLING REMITTANCE $ REMIT i <br /> BASE •I EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT h <br /> FEEA~r Qv� <br /> "w LESS <br /> . PRORATION <br /> PLUS + <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 7 Received by Date a Receipt.No. Permit No. . Issuance Date w Mailed Delivered. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERYICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 1 <br /> -, f <br />