Laserfiche WebLink
"Applications Will Be Processed When Submitted Properly Completed. Be S4M X6+SIT �t1 plication. ~` <br /> FOR OFFICE USE: APPLICATION 4 <br /> (For Non-Transferable, Rerocabie, S 5a n4a�te) P&WELL <br /> ENVIRONMENTAL HEA ERMIT �� 19 1 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> _ - S�� _ . kin y <br /> Application is hereby made to the San Joaquin Local Health District M . <br /> forapermittoconstructand/orinst thO,$�orF ere�ndescribed.This applicationis <br /> jf1 c ; <br /> made in compliance with San Joaquin County Ordinance No. 1862.and the rules-and regtJvl ps of h@ Sa. quln Local Health District <br /> Exact Site Address— :So}J fid- ftT wn <br /> Owner's Name Phone <br /> Address -'�1� City <br /> Contractor's Name _ �' 'r situ "' k" L'icerise#413,72 C Business Phone <br /> Contractor's Address 1°-4 "0 L�a 7- - ",'Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECOND ON 11DESTRUCTION❑; " Y <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER.a 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 ❑ DRILLED Dia. of Well Casing <br /> ❑ OMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> a 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 <br /> Type of Pump H.P. <br /> i PUMP REPLACEMENT: - ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done Cr- <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth �d� <br /> p Describe Material and Procedure <br /> f r <br /> I hereby certify that I have prepared this application and that the work will tie 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 /> I 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 will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X,• - _ Title: Gt�rt 2ek��/ Date: - <br /> (Draw Plot Plan on Reverse 5ide)�/" - `' <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI + <br /> 4. <br /> Application Accepted By �� v3 j -Date <br /> Additional Comments_: ` <br /> Phase II"Grout Inspection r Phasq Ill Final inspection <br /> k" Inspection By - Date Inspection By + Dated <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT' ❑ PER SITE ❑ EACH ❑ January I &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE- -REMIT <br /> BASE EXPLANATION DATE DATE RE I TED AMOUNT DUE' CHECKED- <br /> AMOUNT <br /> FEE i <br /> LESS I <br /> PRORATION - <br /> PLUS - - ..._ s, .S. <br /> 7 <br /> PENALTY , <br /> I � ; <br /> OTHER <br /> i <br /> OTHER <br /> + <br /> Received by Date Receipt No, Permit No. - Iss ance Datel, Mailed Delivered>. <br /> APPLICANT—RETLIRN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />