Laserfiche WebLink
Applications Will BeProcessedWhen Submitted Properly Completed. BeSureToSignTheApplication.. <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 in the work herein described.This application is <br /> made in compliance with San JoaquinGo ntyIi L �Oirdjnance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address i i �*a 28` �i City/Town L C.4 <br /> If Owner's Nam ..._y1 -4 Y' 1� __ Phone x. <br /> Address 1 l c,�"� y City 'd = ? <br /> Contractor's Name d t License#JST;�,3 46 ` Business Phone <br /> Contractor's Addre c-���rti.�ea f 4 �C _ Emergency Phone 'y <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes 4� No <br /> TYPE OF WORK (CHECK): NE'A WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ ViLLs- ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ V <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines l Sr Pit Privy # <br /> Sewage Disposal Field Cesspool/Seepage Pit Otlier <br /> Property Line Private Domestic Well Pubji,c Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation / <br /> 09-DOMESTIC/PRIVATE ❑ DRILLED Dia. of Weld Gasinq <br /> ElDOMESTIC/PUBLIC Cl DRIVEN Gauge of Casin � <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal , -2 b I <br /> ❑ CATHODIC PROTECTION 92—ROTARY Type of Grout W -111i6Z <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 's i N �Sb 6N !. � rl <br /> Type of Pump_._n_�,,) H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done NIT --- <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 inl;'c'cordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations Of the San Joaquin Local Health Distrioc-- -- <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 I i the peltormance,of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws°o C_akforn�'a." ilt+ }}� <br /> I will call for a Grout Inspection prior to grouting and a final inspection. V F <br /> 4 r <br /> Signed ,L�._ � Title: Date: t Q a F\ <br /> (Draw Plot Plan on Reverse Side) <br /> ORD PARTMENT USE ONLY a <br /> PHASE I /f <br /> Application Accepted By -®% �""� { Date <br /> Additional Comments: 711+ <br /> Phase 11 Grout Inspection Phase III Final I Ctign. <br /> Inspection By Date Inspection Byatfr;e�97-2. -2Fee Is Due: 1:1 ANNUALLY ❑ PER UNIT 09 PER SITE 11 EACH El January 1 &Received By January 31 P July 1'+8 Received By July 31 <br /> Bit-LING REMITTANCE $ REMIT <br /> BI <br /> BASE EXPLANAT40N AMOUNT D <br /> DATE DATE REMITTED IdE^ CHECKED <br /> � <br /> AMOUNT' <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS 40 <br /> PENALTY <br /> OTHER <br /> OTHER :t >1 — .• <br /> qJ <br /> Received by IDate t Receipt No, Permit No. ssuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2009 - 570CKTON,CA 96201 <br />