Laserfiche WebLink
Applications Will Be Processed Wh n Submitted Properly o t � <br /> For USE: <br /> '( APPLICATI 1V } ( � <br /> F jelor Non- ransferable, Revod11 , �te�1 able) PUMP&WEE LuU P <br /> . <br /> ENVIRONMENTAL HE <br /> �j <br /> WATER QUALITY t�� t t }` <br /> (COMPLETE IN TRIPLICATE) 000��� t� rein described.This application <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct i t p; <br /> made in complian w' JO ui my Or 1862 and the rules and " Ii thea K quin Loc ealth Distrigt. <br /> i lty/Town <br /> Exact Site Addr s / /� �r�� , <br /> Phone/ <br /> Owner's Name City <br /> Address BusinesWhone —yam <br /> Contractor's Name <br /> License <br /> � t7� T- Emergency Phone, 1 <br /> Contractor's Address t� No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHO? Yes r rt <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN 11 ROC []❑ DESTRUCTION❑ V ` <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 11 PUMP REPAIR <br /> REPLACEMENT❑ RPit Privy <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines <br /> Sewage Disposal Field <br /> Cesspool/Seepage Pit # 1 Other <br /> Property Line Public Domestic Well Private Domestic Well _ <br /> INTENDED USE TYPE OF WELL . . <br /> Well Eavation `1- <br />- © DUSTRIAL <br /> El CABLE TOOL Dia. of Wexc � <br /> ❑ DRILLED Dia. of Well Casing <br /> LJ D _ <br /> OMESTIC/PRIVATE Gauge of Casing <br /> © DOMESTIC/PUBLIC El DRIVEN <br /> ❑ GRAVEL PACK Depth of Grout Seal <br /> 11 IRRIGATION + <br /> 13 CATHODIC PROTECTION ;� ROTARY Type of Grout <br /> 13 DISPOSAL ❑ OTHER <br /> IOther Information <br /> Surface Seallnstalled,By: <br /> 11 GEOPHYSICAL i s <br /> I PUMP INSTALLATION: „Contractor ` <br /> H.P. <br /> .Type of Pump <br /> PUMP REPLACEMENT: i❑J�tate Work Don <br /> jtd State Work Done <br /> E PUMP REPAIR: Approximate Depth <br /> r <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> i ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. I �e <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 /> Y is issued, l s of employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Con or' ring or sub-cont g signature certifies the following:" rtify that in the performance of the work for which this <br /> p mit d all empl per ons subject�tto workman's com anon laws of California." <br /> f I will a t �i r ng and a final irlsp do <br /> Title Date: <br /> 1 Signed XH <br /> -(Draw Plot Plan on Reverse Side)- �- <br /> f <br /> FOR DEPARTMENT USE ONLY <br /> PHASE IA = Date s21 - <br /> Application Accepted By F <br /> Additional Comments: ha a III Final inspection <br /> Phase 11 Grout Inspection Date <br /> i <br /> Date Inspection ByInspection By i <br /> ( Fee is Due' ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE- ❑ EACH .❑ January 1 &Received By January 3} F1 July 1 &RecelveRd REMIT <br /> BILLING <br /> !} BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE - � EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS k/ <br /> PRORATION 4 <br /> PLUS <br /> PENALTY <br /> I OTHER <br /> f OTHER / p <br /> 4 Issuance Date Mailed Delivered <br /> ' Receipt No. Permit No. <br /> Received by Date 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ' <br />