Laserfiche WebLink
Applications Will Be Processed When Submitted Property C t.411111 s _ n�e ��f{I�ation. <br /> 129, <br /> FOR OFFICE USE: APPLICATIO �* L�Lj1J� <br /> (For Non-Transferable, Revocabl pen ) <br /> ENVIRONMENTAL HEALTH PER II �� P � WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY SM jo+QUIN LOCA. <br /> Application is herebymadetotheSanJoaquinLocalHealthDistrictforapermittoconstruct"ilWr in described.This application is <br /> f <br /> made in compliance with San Joaquin Count din n e No. 1862 and the rules and regulations of the San Jol agityfI Local Health District, l <br /> Exact Site Address 0 1 N Off City/Town <br /> Owner's Name - <br /> Phone <br /> Address l V 46 City <br /> T -- I <br /> Contractor's Name License# Business Phone_] S <br /> Contractor's Address Q �' Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ , DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ 1 PUtiFi INSTALLATION �_ PUMP REPAIR <br /> REPLACEMENT.© <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> ' <br /> Sewage Disposal i Field Cesspool/Seepage Pit Other A 00 14-- r_ � <br /> ,i :w Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑,_,,,, INDUSTRIAL El CABLE TOOL Dia. of Well Excavation <br /> UkDO5MESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN .Gauge of Casing ` <br /> ❑ IRRIGATION ❑ GRAVEL PACK depth of Grout Seal A' <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout { <br /> ❑ DISPOSAL ❑ OTHEROther Information <br /> ❑ GEOPHYSICAL Surface S al Installed By: <br /> PUMP INSTALLATION: Contractor ; <br /> k Type of-Pump.� H.P. <br /> PUMP REPLACEMENT: 0 State Work bone ) <br /> PUMP REPAIR: ❑ State Work bone <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that-I have prep 1 <br /> red 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:"t certify that in the performance of the work far which this <br /> permit is issued, I shall employ 'p'ersons subject to workman's compensation laws of California." <br /> 11. <br /> 1 will call for a Grout Inspection!prior to grouting and a final inspection. <br /> r r mss, e_l Date: k <br /> Signed X - Title:��—�-^=--.- - <br /> (Draw Plot Plan on Reverse-Side)�....r-� --- -t <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By --�`+ � � - Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Ph a III Final Inspection <br /> � <br /> Inspection By Date Inspection By Date! <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31- ❑ July 1 &Received By July 31 <br /> BELLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE S S <br /> LESS 3 <br /> PRORATION ' <br /> PLUS <br /> PENALTY <br /> OTHER i <br /> OTHER <br /> Received by Date Receipt No Permit No, Issuance Date Mailed Delivered r <br /> APPLICANT--RETURN ALL-COPIES TO: "ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />