Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ,,OR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> j ENVIRONMENTAL HEALTH PERMIT <br /> E (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 wi h San Joaquin Cot Ordinance No 862 and the rules and regulations of the San J aquin Local Health District. <br /> Exact Site Address City/Town <br /> Owner's Name Phone -,3,: <br /> Address ' City <br /> r 1. <br /> Contractor's Name License#- Business Phone <br /> Contractor's Address r .� Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With JLHD? Yes L--' No C <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION E] W t <br /> WELL CHLORINATION 13 WELL ABANDONMENT 13 OTHER El PUMP INSTALLATION ted" 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 /> ❑ <br /> ,!,ND USTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> I <br /> DOMESTIC/PRIVATE 11 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: 1 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done i <br /> PUMP REPAIR: (] State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ^ 1 <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. ! <br /> i <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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will c fo J Grout Inspec iontprior to grouting and a final inspection. <br /> Signed _ Title: '��-E�l� Date: Aq:2_`&-i <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT^USE ONLY <br /> PHASE / <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection ase III F' I Inspection <br /> Inspection By Date Inspection By Date <br /> I <br /> Fee Is Due: ❑-ANNUALLY ❑ PER UNIT ❑,PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Jufy 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> f� AMOUNT <br /> FEE ! � rY J r 1 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> O L Id V rS <br /> Received by Date Receipt No. f Permit No 15 uance date I Mailed Delivered <br /> APPLICANT—RETURN ALL COPfES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.-HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 96201 <br />