Laserfiche WebLink
.z...aons`Will Be Processed When Submitted Properly Completed. S Sign The Application. <br /> FOR OFFICE USE: _ APPLICATION <br /> d� (For!don=Tr'a'nsferable, Rev S Pd le) <br /> It PUMP&WELL <br /> ENVIRONMEN A PER1� <br /> WA (IALETY <br /> (COMPLETE IN TRIPLICATE � C qq ��p�� <br /> Applicatie,liskerebymadetotheSanJoaquin Local Health Districtforap toc, rOatand/orint111T£rhi workhereindescribed.Thisapplicationis <br /> made in c-,;mp1iance with San Jo '' ounty Or e No. 1862 and he rules and ree I>XXl 4���t5 oaquin c �jth District. <br /> q crrr� <br /> Exact Sits Addres 6� & own <br /> Owner's Na Ph on 104 Dl <br /> r <br /> AddressCit <br /> Contractor's Name License Business Phone Ifi <br /> Contractor's Address ir Emergency Pho� , <br /> Is Certificate 1 f Workman's Compensation Insurance on File With 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❑ <br /> F <br /> DISTANCE T6 NEAREST: Septic Tank Sewer Lines Pit Privy ' <br /> Sewage Disposal Field Cesspool Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE I TYPE-OF WELL " <br /> ❑ INDUSTRIAL_ ❑ CABLE TOOL Dia, of Well Excavation <br /> ❑ <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 /> ❑ <br /> DISPOSAL! ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL rface Seal Installed By: , <br /> PUMP INSTALLATION: Contractor X de <br /> Type of Pump H.P. , <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: i ❑ State Work Done ' <br /> DESTRUCTION OF WELL: I Well Diameter Approximate Depth <br /> Describe Material and Procedure f <br /> i <br /> I hi <br /> ereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state Iawsland rules and regulations of the Sart Joaquin Local Health District. k <br /> Homeowner or licensed agent's signature certifies the following:"1 certity that in the performance of the work for which this permit <br /> is'dssued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's or sub-contracting signature certifies the following:"I cero#phat in the performance of the work for which this <br /> FgKn�sption <br /> lltl sons subject to workman's compensate laws of California." <br /> I nor to gr fling and a final inspec <br /> aJ <br /> Signed X !r Title: pate: <br /> —(Draw Plot Plan on Reverse Side)._ <br /> F R DEP RTMENT SE ONLY <br /> 'I <br /> PHASIt ILI ly <br /> Application Accepted By © Date 4;2&1 <br /> Additional Comments: 4 k <br /> Phase II Grout Inspection Phase Ill Final Inspection <br /> Inspection By Date Inspection By OeE-- Date 2-1—ACI <br /> Fee Is Due: ❑ ANNUALLY- �, ❑ PER UNIT Ar PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMfT <br /> BILLING REMITTANCE $ <br /> 6 ` <br /> BASE�� EXPLANATION AMOUNT DUE CHECKED <br /> til REMITTED DATE DATE <br /> , AMOUNT <br /> FEE <br /> n. - <br /> LESS <br /> PRORATION 'I <br /> PLUS <br /> PENALTY ..� <br /> .I�OTHER1i , <br /> Ii <br /> OTHERIi <br /> i Ali ff ry <br /> Received by Date. - _ Receipt No. -- Permit No Issuance Date Mailed Delivered -� <br /> APPLICANT—RETURN ALL COPIES TO:--ENVIRONMENTAL'HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 45201. <br />