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, Hevucable;Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permitto construct and/or install thework herein described.This application is <br /> made in compliance with 5a Joaquin County Ordinance No. 1862 an the rules and regulations of the San Joaquin L6oce th District. <br /> Exact Site Address City/Town - -- <br /> I � <br /> Owner's Name �- l o Phone <br /> Address /Z I`.ar' -+ Clty <br /> Contractor's Name ''License#m Business Phone 2.-- <br /> Contractor's Address Emergendy Phone <br /> Is Certificate of Workman's Compensation Insurance on File4ith SJLHD? Yes No <br /> TYPE OF WORK (CHECK)"'"NEW WELL❑ DEEPEN ❑- - RECONDITION❑ DESTRUCTION❑ - <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT i } <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 /> "0 DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor? -fL�r- F <br /> i <br /> Type of Pump�"rcv�rJtnf'S• G.1 H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: y a ❑ State Work Done r! <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth Lj <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 /> 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 c I for a Gr nspection prior to grouting and a final inspection. <br /> Signed X ' + °' Title: .., Date: 9__6 ,RJ <br /> (Draw Plot Plan on Reverge Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE i i <br /> Application Accepted By Date . <br /> Additional Comments: <br /> Phase,I Grout Inspection s I I Final Inspection <br /> Inspection By Inspection By Date <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 /> BASE' EXPLANATION ' DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE' -� <br /> LESS y <br /> PRORATION <br /> PLUS r _ <br /> PENALTY <br /> ' OTHER <br /> -:-OTHER r.. <br /> � �, <br /> Received by Date Receipt N0. Permit No. Issuance Date Mailed Delivered <br /> i APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES v. 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />