Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. t <br /> =(COMPLETEIN <br /> APPLICATION <br /> (For Non-Transferable, Revocable;Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> ATE) <br /> WATER QUALITY T ; <br /> Application is hereby-made to he San Joaquin Local Health District for apermittoconskructand/orinstallthework.hereindescribed.Thisapplicationis <br /> made in compliance: in Co ty Ordina c No. d the le nd regul tions of the San a uin L-c ealth District. <br /> •�-{ � City/Town <br /> Exact Site Address <br /> Phone <br /> Owner's Name bV City <br /> Address <br /> Contractor's Name 4' Y License# Business Phone <br /> Contractor's Address y :r1 y ; "Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No S. <br /> TYPE OF WORK (CHECK): NEW WELL,-_DEEPEN ❑ RECONDITIONS❑ ' DESTRUCTION❑ <br /> ♦ <br /> -,,., ��' ❑ OTHER ❑''' P[1MPP NSTALLATION❑' PUMP FtEPAIFj❑ <br /> WELL CHLORINATION ❑ WELL' ABANDONMENT <br /> p' o>�+++`"-� dal+-.'�� 1a .��i:ra� �.•e� ���^' ti� A%y �°`-'' �•:1'4s � � c <br /> REPI'ACEMENT'0 h, = <br /> DISTANCE TO NEAREST: Septic-Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage,Pit <br /> Other 2 <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ INDUSTRIAL ` <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 11 IRRIGATION <br /> GRAVEL PACK Depth of Grout Seal <br /> El CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL <br /> ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By:: <br /> PUMP INSTALLATION: Contractor <br /> 0,441 <br /> Type of Pump . S H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done ` �A] <br /> DESTRUCTION OF WELL: Well Diameter I` 4 Approximate Depth <br /> Describe Material and Procedure F <br /> I hereby certify that I have prepared this'�a, pplication and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and rel Iations of-the-S`an Joaquin Local Health District. <br /> Home owner or licensed agent's signature'ertities the tojjowing:"I certify that in the performance of the work for which this permit <br /> q is issued, 1 shall not employ any person in such manner as to become subject to workman's compensation laws "Ca <br /> I Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> » I will 'all for a Grout Inspe tion pri Y to grouting and-a final inspection.r Date:Signed X l Title: <br /> (Draw Plot Plan on Re verse Side) <br /> _ FOR DEPARTMENT USE ONLY <br /> PHASE I l Date <br /> Application Accepted By <br /> Additional Comments: <br /> i ase 11 Grout Ins ection ase Ill Final lrip ection <br /> I .��bate -Sv��-�� Inspection By T Date^�S <br /> Inspection By -A <br /> Fee Is Due: ElANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received EB'ylJuly 31 <br /> F BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS _ Ykti <br /> PENALTY _ <br /> w- <br /> OTHER <br /> OTHER ? a v <br /> Received by D to Receipt No. Permit No. Issuance Date Mailed Delivered <br /> 1601 E.HAZELTON AVE., .O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />