Laserfiche WebLink
,. Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The �iplidation. A <br /> OFFICE USE: APPLICATION 3LL..�33 1 <br /> (For Non-Transferable, Revocable, Suspendable) PUMP 8, <br /> ENVIRONMENTAL HEALTH PERMIT q!js 3/;.Qi"N LOr"AL } <br /> WATER QUALITY HEALTH,H, US I MT <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health District permit construcfand/or inskall the work herein described.This application is <br /> made in Compliance with an Joaquin County Ordinance No. 1862 and the ules and regulations of the San Joaquin Local AWDistrict. <br /> Jealth <br /> Exact Site Address 1 �i I ti City/Town <br /> 3Aw <br /> Owner's Name _ <br /> NI► ! lf�Al Phone <br /> �q <br /> Address - City <br /> Contractor's Name i . License# [� Business Phone_ <br /> /.� • �'""' EmergencyPhone �'�� �y <br /> Contractor's Address ,03' �J/� <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes NO <br /> TYPE OF WORK (CHECK NEL � ❑ RECONDITION <br /> ❑ INSTALLATION ❑ <br /> WELL CHLORINATION WELABDONMENT 0 OTHER ❑ PUMP PUMP REPAIR <br /> l <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 <br /> TYPE OF WELL <br /> ❑a INDUSTRIAL 11 CABLE TOOL Dia. of Well Excavation <br /> Oa 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: (� i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work pone I` <br /> PUMP REPAIR: I-State Work Done . <br /> DESTRUCTION OF WELL: <br /> Well Diameter Approximate Depth y� <br /> l <br /> Describe Material and Procedure. I <br /> 1`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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> Ho <br /> is issue <br /> me o 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 i <br /> permit is issued;1 shall employ persons subject to workman's compensation laws of California." „ <br /> i" <br /> I-wippall for a Grou spe� n prior to grouting and a final inspection. <br />` <br /> Title. "Date: ZT.r 4 . <br /> Signed X <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> zi, <br /> k w PHASE 1 In Date 1 r <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout Inspection �"11L-r�� �`� ��.y ,hase III Final Inspection <br /> .' Inspection By Date Inspection By <br /> Datta, <br /> ' Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH C3January 1 &,Received By January 31 ClJuly 1 &Recewd By <br /> REMlTuly 31 <br /> BILLING REMITTANCE $ AMOUNT DUE 'CHECKED <br /> BASE EXPLANATION <br /> DATE DATE REMITTED AMOUNT <br /> FEE 1� <br /> t <br /> LESS <br /> PRORATION y��_ n'• ,s` '] <br /> t PLUS 1 '� Li yt G�eCf� f <br /> PENALTY <br /> OTHER <br /> OTHER _ <br /> Permit No. Issuanc Date <br /> Receive by ate Receipt No. "Mailed - Delivered .. <br /> APPLICANT—RETUR ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZELTON AVE.,P.O.Box 2004 STOCKTON,CA 95201 <br />