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) (Z 6 SS U_) Gr__ TER QUALITY o S 0 :?_6 <br /> Application is hereby made to the San Joaquin Local Health District fora perriiit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address oA ln'�, /�G'�G 4111WIlesliL- 'lT Y� City/Town <br /> I <br /> Owner's Name _._ 3'dl-sri' lE� ILL' S-rte , — Phone <br /> Address Olv ` I ad. _ City <br /> Contractor's Name J!� o �� License# .3a�-0/1 Business Phone <br /> Contractor's y7�w <br /> Contractor's Address ZA// S'1 T �� �e Emergency Phone �ftaJ- S.2'- <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes !/ No I <br /> TYPE OF WORK (CHECK):- NEW WELL❑= DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 21 PUMP REPAIR❑ <br /> REPLACEMENT❑ 11 <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 Jv <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 ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL �7 Surface Seal Installed'By: ^ <br /> PUMP INSTALLATION: Contractor e � v f 9 Z <br /> Type of Pump } H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> r. <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure I <br /> I hereby certify that's have prepared this application and that the work will be done in accordance with San Joaquin County t <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <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-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 will call fora Grout Insp tionQprior to grouting and a final Inspection. <br /> Signed X �c G . Title: At Date: <br /> j (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final Inspection a <br /> Inspection By Date Inspection By tz4^- Date �� G <br /> 1 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January-1 &Received By January 31 ❑ July 1 &-Received By July 31 - <br /> BILLING REMITTANCE REMIT <br /> $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE D <br /> AMOUNT <br /> FEE , <br /> LESS <br /> PRORATION <br /> PLUS { r <br /> PENALTY <br /> OTHER <br /> r <br /> OTHER <br /> Received by bat4 Receipt No Permit No. Issuance Date Mailed Delivere f <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA2ELTON AVE.,P.O.Box 2002 STOCKTON, 95201 1lJ <br />