Laserfiche WebLink
Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. <br /> F,:oR OFNCE USE: APPLICATION <br /> (For Non-Transierable, Revocable,Suspendabie) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with n Joaquin County Ordin ce N .Z;62 and the rules and regulations of the San Joaquin Local Health District, <br /> Exact Site Address City/Town C—Owner's Name lR Phonea� - {�f�fh� } <br /> Address e� we- City— <br /> Contractor's Name dA1 �,1 Ie AAzicense Business Phone <br /> Contractor's Address Emergency Phone7Sr— eV1z9 <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 ❑ 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 /> INTENDED USE TYPE OF WELL. <br /> ❑ INDUSTRIAL ❑ CABLE TOOL• Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE --D-DRILLED — --Dia- of Well Casing- <br /> 0 <br /> asing❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal W1 <br /> CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> �r <br /> ❑ DISPOSAL OTHER Other Information i <br /> ❑ GEOPHYSICAL Surface Seal Installed B%i, <br /> . <br /> PUMP INSTALLATION. Contractor <br /> Type of Pump H.P. t <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: JS State Work Done 69f� �IV <br /> DESTRUCTION OF WELL: Well Diameter v 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 thework for which this permit i <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> , 7 <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 wi all for rout Inspeotion rior to grouting and a final inspection. <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY — <br /> PHASEI � <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Rhase,IIIincl spection <br /> Inspection By T Date T _ Inspection By -- -46 Date �IR a_ <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 .( <br /> REMIT \' <br /> BILLING REMITTANCE $ <br /> BASE � EXPLANATION AMOUNT DUE CHECKED <br /> " •4 DATE DATE REMITTED AMOUNT <br /> FEE . CS <br /> LESS y��- <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER ...� Ali > <br /> OTHERrn <br /> 456 QC1 <br /> �- Received by Date Receipt No. Permit No. Issuance Date Mailed Del red <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKT+ 5201 <br />