Laserfiche WebLink
.' M., ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: �+b APPLICATION <br /> i (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY2� 0,51 W <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 atl��the rules an regulations of the San Joaquin ca H altil District. <br /> Exact Site Address r� !V/ K/ City/Town <br /> Owner's Name Z t Y�^r A a:.0-0 Gz t Phone <br /> Address 'a city <br /> Contractor's Name License# /Jr3"7 w_ Business Phone _ , y —76 <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File Wi SJLHD? Yes— -- No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <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 n <br /> Property Line Private Domestic Well 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 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Sea] <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface 5_,_eal Insta <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 0" H P <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ON State Work Done d& <br /> DESTRUCTION OF WELL: 01 <br /> 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 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 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I vfjll call for a Grout Inspectio p ' r routin and a final inspection. <br /> Signe itle: rr _ Date: <br /> (Draw Plot Ian on Reverse Side) <br /> F R PARTM ' T E ONLY <br /> PHASEI <br /> Application Accepted By <br /> Date <br /> Additional Comments: <br /> Phase II rout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By 0,167 Date 49 � <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 R Received By January 31 ❑ Juiy 1 &Received By July 31 <br /> BILLING REMITTANCE REMIT <br /> BASF EXPLANATION $ AMOUNT DUE CHECKED <br /> �j DATE DATE REMITTED <br /> FEE C//G 6 AMOUNT <br /> LESS <br /> PRORATION ' <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,C <br />