Laserfiche WebLink
ApplicationsWill BeProcessed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendabie) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) �'L7 la2, j `a1 E� QUALITY <br /> Application is hereby made to the San Joaquin Local Healt +Dist o a ermittoconstructand/or install the work herein described.This application is <br /> made in compliance wjth San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address I _ _ + _lCity/Town E-�4 <br /> Owner's Name -TDG;F-_ c� ��a?r/ _ Phone <br /> Address r! ►►1 / IO. City .Sr-eve'-o sc9 <br /> Contractor's Name Uti 1�t;y_PS rAZ- PUAAA ¢ SVIFa4 License f ��6/ Business Phone 411. ` <br /> Contractor's Address &7,1 /�• ��a�3�fJJI�` Tib' Emergency Phone �51 -m _ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No n <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT OTHER 13PUMP INSTALLATION PUMP REPAIR 13 <br /> REPLACEMENT❑ f } <br /> DISTANCE TO NEAREST: Septic Tank a ZS Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> P=rope Line Private Domestic Well Public Domestic Well <br /> INTENDED USE �I�S`t�-x'1 TYPE OF WELL r <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 4� <br /> DOMESTIC/PRIVAT WELL ❑ DRILLED Dia. of Well Casing J <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 <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor i✓Yr E ✓��� <br /> Type of PumpRJ f�C/L.f +~1_— ��J 43I-r?4�; -I18L-d— H.P. l <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done --� <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth 11910zJ� <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 h' ng or ub-contracting signature certifies the following:"1 certify that in the performance of the work for which this <br /> permit iWrou <br /> II mp perso subjec o workman's compensation laws of California." <br /> I will caInspeciio pri r uting and a final inspection. r� <br /> Signed X Title: &,-s' Date: <br /> (Dra _Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date �e f <br /> Additional Comments: <br /> Phase 1 rout Inspection1 Final Inspection <br /> Inspection By Date Inspection By f Kase 1Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UN ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July t &Received By July 31 <br /> AEWT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> r , DATE DATE REMITTED AMOUNT <br /> FEE <br /> 55 V L 5� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 13agI cli <br /> Received by Date Receipt No. Permit No. 1 suance D to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />