Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. / <br /> FOR OFFICE USE. _.� APPLICATION <br /> (For Non-Transferable,Revocable;Suspendable) 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 install the work herein described.This application is + <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the.rules and regulations of the San Joa uin Local Health District. <br /> Exact Site Address I CitylTown <br /> Owner`'s Name ' ate.. '�' 4. Phoned r <br /> Address City' " ;; f yk1aa x <br /> Contractor's Name " License# ' * Business Phor e0' <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No r <br /> TYPE OF WORK (CHECK). NEW WELL❑ ' DEEPEN 0 RECONDITION❑ DESTRUCTION❑ `\ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ l <br /> REPLACEMENT D <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 Y <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 Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: f <br /> PUMP INSTALLATION: Contractor -�— <br /> Type of Pump -r H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done . <br /> DESTRUCTION OF WELL: Well Diameter ! Approximate Depth <br /> Describe Material and Procedure z <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 forwhich 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to-grouting and a final inspection. <br /> i . <br /> Signed X -- Title: ` ' Date: <br /> (Draw Plot Plan on Reverse Side) I { <br /> F <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By j Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection P"tp III Final Inspection <br /> a <br /> -Inspection B Date-- -Inspection B . Date Z <br /> Fee Is Dile: ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH i ❑ January I &Received By January 31 ❑ July 1 &Received 8y July 31 <br /> r .BILLING- REMIT <br /> ,BASE- EXPLANATION REMITTANCE $ AMOUNT DUE CHECKED <br /> - DATE DATE` REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRO TION <br /> PLUS. _. <br /> PENAL Y' 1 <br /> OAR <br /> s <br /> OT4W I" <br /> r <br /> I-IT <br /> Received by - Date Receipt No.'s Permit No. Issuance Date -- Mailed -_•Delivered- <br /> APPLICANT—R URN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9520 <br /> sr Z <br />