Laserfiche WebLink
F 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 /> i- ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) ; <br /> (COMPif" _ <br /> Application is hereby made to the San Joaquin Local Health District for a•permit to construct and/or t <br /> install the work,herein described.This application is <br /> made in compliance with an.Joaquin Co my Ordinanc No.1862 Land the rules and regulations of the San oa4laiq Local Health District. <br /> �, City/Town b -c <br /> Exact Site Address_ � — <br /> Phohe <br /> - 3 . <br /> Owner's Name a <br /> Address �e City /- <br /> Contractor's Name /-=� L`t-' L-+cense#` __ Business Phone <br /> Contractor's Address d 7`' Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes .1/ No <br /> TYPE OF WORK (CHECK): NEW WELL❑' 'DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ I <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIREB/� ) <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Oma( <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Do em stic.Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL s <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 1!1 <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 1 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> l ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ` <br /> r ❑ ROTARY Type of Grout <br /> ❑ CATHODIC PROTECTION <br /> ❑=DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL ✓7 Surface Seal Installed By; <br /> PUMP INSTALLATION: Contractor <br /> Y �y <br /> Type of Pump H.P. <br /> k <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done e — <br /> I imateApproxDepth <br /> DESTRUCTION OF WELL: Well Diameter # f <br /> Describe Material and Procedure z <br /> 11that'1 have prepared this'applicatian 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:"1 certify that in the performance of thelrvork for which this permit <br /> is issued, I shall not employ any person-in such manner as to become subject to workman's comp6risation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"l certify that in th`performance of_the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California."%+ i <br /> I will qg@ for a Grout I pection-prior o grouting and a final inspion. # <br /> Signed X Title: Date: 1(Draw Plot Plan on Revers Side) <br /> �114� <br /> 1. <br /> FOR DEPARTMENT USE ONLY <br /> ` PHASE I - ') sti f"y lj <br /> Application Accepted By 4 _ ' pr` Date { <br /> Additional Comments: <br /> Ph se II Grout Inspection Phase Ill F"_al'lnspecflon <br /> Inspection By Date Inspection By Un`" 'Date <br /> } Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> 'BASE EXPLANATION- DATE DATE REMITTED, AMOUNT <br /> FEE <br /> LESS <br /> PRORATION i y III a <br /> PLUS <br /> PENALTY i Tw <br /> OTHER i <br /> OTHER <br /> Received by 1 Date- Receipt No. Permit No Issuan ate .Mailed- - Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERYICES 1601 .HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201.' <br />