Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Cor yiete�OE: ie 5orie �7!, , 4F,C�a"� �A rl <br /> FOR OFFICE USE: APPLICAT10 }tl :=� If 'I <br /> y (For Non-Transferable,Revocabl ,ICS.r(spendable) P &WELL <br /> c 1.�3 <br /> ENVIRONMENTAL HEALTH PERWO 3 0 1981 tis t <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) oSA A"A^,f),��° I'� o.Wa s j� <br /> Application is herebymadetotheSanJoaquinLocalHealthDistrictforapermittoconstru o trt3�ltlty�iA atKtndescribed.Thisapplicationi 1� <br /> made in compliance with San Joaquin Cloun,y rdoance No. 18 2 and the rules and regulk4tart�5 of�he <br /> 31h qul Local Health District. <br /> // t l y City/Town <br /> Exact Site Address � - i � i <br /> Phone -3 r <br /> Owner's Name <br /> Address G City 3 _ 3 C <br /> Contractor's Name . �' License# 373 Business Phone <br /> Contractor's Address ,� Emergency Phone f <br /> c.� No nj <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION El DESTRUCTION El <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field _ Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well_ _ Public Domestic Well <br /> IGEOPHYSICAL <br /> TENDED USE TYPE OF WELL ' <br /> ❑ CABLE TOOL Dia. of Well Excavation <br /> MES RIVATE ❑ DRILLED Dia. of Well Casing <br /> MESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> THODIC PROTECTION ❑ ROTARY Type of Grout <br /> POSAL ❑ OTHER Other Information <br /> Surface Seal I tolled By: <br /> PUMP INSTALLATION: Contractor <br /> P <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done r, <br /> PUMP REPAIR: - U/State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> r <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 per <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." <br /> � <br /> IW all r a Grout I pection prior to uting and a final Inspection. r` <br /> Dale: rL <br /> Signed X <br /> (Draw Plot Plan on ReversSide) T <br /> FOR DEPARTMENT USE ONLY 4 <br /> PHASEI �1 <br /> Date �—� <br /> Application Accepted By <br /> Additional Comments: <br /> Phase I Inspection Phase III F'n I�lspection <br /> Inspection By Date Inspection Byffi5f Date <br /> Fee IS Due: ❑ ANNUALLY PER UNIT ❑ PER SITE EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivREMITBY uIy 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by <br /> Date Receipt No Permit No. suance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />