Laserfiche WebLink
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 /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY,•, ,. 3,.- F n,. r* ' <br /> Application is hereby madeto the San Joaquin Local Health Districtfora permitto construct and/or install thework herein described.This application is <br /> made in compliance with San Joaquin County Ordinan No.;1862 and the rules a d egulations of the San aquin Local Health District. <br /> Exact Site Address 0 LIP City/Town <br /> Owner's Name Phone r <br /> Address 0 City <br /> Contractor's Name License# l� Buussiness�hone -3 16 <br /> Contractor's Address 0- ' Emergency Phone r 3 Ir <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ . PUMP INSTALLATION ❑ PUMP REPAI <br /> REPLACEMENT❑ t <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 /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL <br /> ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor i <br /> Type of Pump H.P. I <br /> PUMP REPLACEMENT: ❑ State Work Done _ <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure j <br /> I 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 rF <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 ill call for a Grou Inspection prior to grouting and a final inspe on. <br /> —�( �"el . " <br /> Signed X Title s Date. +� <br /> raw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY G <br /> PHASEI <br /> Application Accepted By <br /> Additional Comments: ' <br /> Phase II:Grout Inspection aseElll 1 ction <br /> Inspection By bate Inspection By to 3�� Z <br /> Fee IS Due: ❑ ANNUALLY` "q ❑ PER UNIT ❑ PER SITE ❑ EACH - ❑ January 1 H eived By J ry 31 ❑ July 1,&Received By July 31 <br /> BILLING REMITTANCE $,. REMIT <br /> ' BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED. AMOUNT <br /> EEE 03— <br /> Cv <br /> LESS 1 TL A41 <br /> PRORATIONPLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> r <br /> BS34 . 1 d 3a �8 <br /> Received by - Date Receipt No. Permit No issuance D to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 ry` <br />