Laserfiche WebLink
Applications:Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: �� APPLICATION <br /> y � / (For Non-Transferable, Revocable,5uspendable) J PUMA&WELL <br /> ENVIRONMENTAL HEALTH PERMIT J <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <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 San Joaquin County O�nance NY. 1862 and the rules and regulations of the San JoIIAA_1 J1ocal Health Distr'ct. <br /> Exact Site Address I' +! City/Town "�Y�i�.af' ,• <br /> Owner's Name Phone <br /> Address G . . :n City_ fir ' - pd <br /> Contractor's Name r ,- License# Business Phone <br /> Contractor's Address Emergency Phone• '4 j <br /> Is Certificate of Workman's Compensation Insurance on File ith SJLHD? Yes X No '�_ <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN RECONDITION❑- DESTRUCTION❑ 0 <br /> WELL CHLORINATION ❑ WILL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other- <br /> Pro rty <br /> therProperty 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 /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL I Surface Seal Installed By:" <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - H.P, <br /> PUMP REPLACEMENT: , ❑ State Work Done I <br /> Pt1MP0" ❑ State Work Done <br /> DESTRUCTION OF WELL: I Wel! Diameter A <br /> ppro mate Depth <br /> Describe Material and Procedure <br /> F <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 /> _ I <br /> Homeowner or licensed' gent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, I shall not em6Ioy 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I ill call for a Grout Inst eitftn r o o o ing and a final inspection., <br /> Signed all <br /> I itle: !&r Date: �. <br /> (Draw PIo an on Reverse Side) <br /> FOR DEPARTMENT USE ONLY - <br /> PHASE I ` <br /> Application Accepted By rea Date I <br />` Additional Comments: l <br /> Phase,�l! Grout Inspection Phase III Final Inspection <br /> Inspection By l Date. 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 /> 1�i <br /> REMIT <br /> BASEEXPLANATION BILLING REMITTANCE $ AMOUNTDUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE Asl.N, <br /> LESS 5 I <br /> PRORATION <br /> PLUS <br /> PENALTY 'I� fJ✓ - - ' <br /> OTHER r �� <br /> OTHER <br /> Received by Date :IY Receipt No. Permit No.. Issuan a Date. Mailed Delivered <br /> I APPLICANT—RETURN ALL COPIES <br /> II TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bo=2009 STOCKTON,CA 9620 <br />