Laserfiche WebLink
"4'plicaiions Will Be Processed When Submitted Properlycompieiea. oe auTc �y• ^rte <br /> ° APPLICATION <br /> FOR OFFICE'USE: <br /> (For Non-Transferable, Revocable,Suspendable) pUMP &WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> 9` WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) lication is <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described-This application <br /> made in compliance with San Joh ui un rdinance No. 1862 and a rules and regulations of the San C Local Health District_ -- <br /> Exact Site Address _ <br /> A' <br /> City/Town <br /> Phone <br /> Owner's Name City <br /> Address <br /> Contractor's Na �Y— CW <br /> L�erase#�6�g�1 Business,PYlone <br /> Emergency Phone <br /> Contractor's Address No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_�� � <br /> TYPE OF WORK (CHECK): NEW WELL�� DEEPEN 13RECONDITION❑ DESTRUCTION❑ � <br /> WELL CHLORINATION 13 WELL ABANDONMENT El OTHER C3 PUMP INSTALLATION L��1PUMP REPAIR <br /> � <br /> REPLACEMENT❑ / Pit Privy v- <br /> ISey <br /> DISTANCE TO NEAREST: Septic Tank /aer Lines Other <br /> Sewage Disposal Field Cesspool/Seepage Pit <br /> Property Line Private Domestic Well <br /> Public Domestic Well <br /> '°^'�' <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL 13 CABLE TOOL Dia. of Well Excavation S <br /> ❑ DRILLED Dia. of Well Casing <br /> DOMESTIC!PRIVATE Gauge of Casing <br /> 11DOMESTIC/PUBLIC ❑ DRIVEN <br /> ❑ <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ��-•�p8./j " <br /> j <br /> 13 CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ OTHER Other Information <br /> t ❑ DISPOSAL <br /> f ❑ GEOPHYSICAL rface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P- / <br /> PUMP.REPLACEMENT: <br /> ❑ State Work Done ' <br /> PUMP REPAIR: ❑ State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: <br /> 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 /> C <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> a <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-co . racting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall emp y rsons subject to workman' laws of California." <br /> s compensation <br /> Ill call for a Gro t In e p or to grouting and a final inspection. CC <br /> Title: Date: <br /> Si n (Draw Plot Plan on Reverse Side) <br /> a, FOR DEPARTMENT USE ONLY <br /> PHASE I Date Bpi <br /> E: Application Accepted By <br /> Additional Comments: P ase Ili Final inspection <br /> Phase 11 Grout Inspection <br /> Inspection B � Date Inspection By <br /> Fee is Due: ❑ ANNUALLY ❑ R UNIT- ❑ PER SITE ❑ EACH ❑ January 1 S Received By January 31 July 1 &Received EMITu1y 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> - BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> `Q 'Q Q <br /> FEE (J(J O <br /> LESS <br /> PRORATION <br /> C PLUS <br /> PENALTY <br /> OTHER <br /> t - <br /> OTHER �n <br /> Issuance Date Mailed Delivered <br /> '+ -----"s" <br /> —Receipt-No. - - Permit No- - _ <br /> c Received by — bate P ^"".`-"- .'- _ - ... <br /> - 1601 E.HAZELTON AVEC P.O.Box 2005 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: � ENVIRONMENTAL HEALTH PERMITlSERVICE5 <br />