Laserfiche WebLink
Application's Will Be Processed When Submitted ProperlyCompleted. Be SureToSigTheApplication. <br /> FOR OFF,JCE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable �� <br /> PUMP&WELL <br /> I ENVIRONMENTAL HEALTH PERMIT <br /> kWATER QUALITY <br /> (COMPLETE IN TRIPLICATE) I ' <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with ] Jo Ip in C unty 0 d'�'ance No. 1882 and the rules and regulations of the San J a In Loc I Health District. <br /> Exact Site Address `r _! 1--eAfP 1b, City/Town _. G ¢ C <br /> i Owner's Name Ii �aS Phone rt - 4y- T y1 v <br /> Address • di L0LCity �t �i <br /> Contractor's Name �`itw` r. W1rC.1,A- 1.�CQ01IP License#�r 6a Business Phone LLQ <br /> Contractor's Address UW1*4 A II;6 W Ay Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ~� No <br /> TYPE OF WORK (CHECK): NEW WELL D4 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ �1 <br /> Il t <br /> DISTANCE TO NEAREST: Septic Tank 'r Sewer Lines Pit Privy <br /> Sewage Disposal Feld Cesspool/Seepage Pit Other <br /> Property Line Private Private Domestic Well Public Domestic Well <br /> I INTENDED USE i TYPE OF WELL �r <br /> 6 El INDUSTRIAL <br /> 11 CABLE TOOL YDia. of Web Excavation �G <br /> DOMESTIC/PRIVATE 11 DRILLED : .. ; Dta. of Well Casing- = ' <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge-df-Casing <br /> Svc <br /> ❑ IRRIGATION ❑ GRAVEL PACK••'"' Depth of Grout Seal �--- <br /> ❑ CATHODIC PROTECTION -,,119-ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Iniorrpa(,ion <br /> t ❑ GEOPHYSICAL Surface Seal Installed By: t <br /> r f� <br /> i PUMP INSTALLATION: Contractor <br /> i Type of Pump H.P. . <br /> "' PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ! ❑ State Work Done <br /> DESTRUCTION OF WELL: of Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i I hereby certify that Ii.have prepared this application and that the work will b'e done in accordance with San Joaquin-t U tT <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health'Diptr.ict. <br /> Homeowner or licensed ageni's signature certifies the following:"I certify that in-the performance of the workforwklich this permit <br /> is issued, i shall not,employ any person in such manner as to become subject"tn,workman's compensation laws W CalVornia. <br /> . <br /> Con actor's hiring iorjsub-contracling signature certifies the following:"I certify.that in tKe performapr e'of the work for which this <br /> x ti. � " <br /> -per i is issued, E shall employ persons subject to workman's compensation laws of California." - <br /> .. - <br /> I wil II for a Grptl�l pe' <br /> nor grouting and a final inspection. <br /> Signed X Title: TT " ��:` Date: + r E L�11 <br /> g i� (Draw Plot Plan on Reverse Side) <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - j� <br /> Application Accepted Byll / Date:—A/ <br /> Additional Comments: z i �,._- _ <br /> hase II Grout Inspection ase 111 Flpal Inspection' <br /> Z4 <br /> Inspection By A^ -Date � Inspection-by <br /> - Date,c��� y <br /> r- 7 �^ <br /> Fee Is Due: ❑ ANNUALLY ' ❑ PER UNIT ❑ PER SITE ❑ EACH � iianuary'k &Received By Janua"ry 31 ❑ July-1 A Reci3rveti'89'July 31 <br /> REMIT <br /> ��. BILLING REMITTANCE r..3"""$ AMOUNT DUE "61iEG1<ED <br /> BASE' EXPLANATION <br /> Jy, DATE DATE . s REM'rTTED .�- �AMOIJNT <br /> FEE 43 t <br /> «..,,.LESS <br /> PRORATION""' <br /> PLUS <br /> PENALTY <br /> OTHERw <br /> III ,n.s--=�.�:r*•- <br /> OTHER p <br /> �' Received by Dat2e Receipt No. Permit No. Issuan a at, Mailed Delivered=. <br /> ' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />