Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed.Be Sure ToSignTheApplication. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT h <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> ApplicationisherebyLICATmade to theSanJvaginLc. Health District for a permit to contructand/or install the work hereindescribed.This application is <br /> made in compliance with San oaquin C nce .1862 and t e rules anAregulations of the San J�ppquin Lopal Health District. + <br /> Exact Site Address <br /> r City/Town A 4 <br /> Phone <br /> Owner's Name d <br /> Address City <br /> Contractor's Name { License# ?>—JIT-2—Business Phone Z <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's CompensationI surance on File With SJLHD? Yes2( <br /> No J <br /> TYPE OF WORK (CHECK): NEW WELLS DEEPEN El RECONDITION <br /> DF <br /> STRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field,l f1 c Cesspool/Seepage Pit .� Other— <br /> Property <br /> � <br /> Property Line_Private Domestic Well_ ,� Public Domestic Well ! <br /> INTENDED USE TYPE OF WELL rr <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> DOMESTIC/PUBLIC, ElDRIVEN Gauge of Casing I <br /> ❑ IRRIGATION RAVEL'PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION OTARY Type of Grout 'p <br /> ❑ DISPOSAL OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: Y <br /> J <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ state Work Done <br /> PUMP REPAIR: ❑ State Work Done. <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> i Describe Material and Procedure <br /> i 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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich 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 /> 1 Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> 4 permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> t will c for a Grout 1 s tion prior to grouting and a final inspection. V-1—P711�4Pz�_ <br /> Signed X Title: Date: <br /> + (Draw Plot Plan bin Reverse Side) r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Date <br /> Application Accepted By <br /> Additional Comments: <br /> j Phase 11 Grout Inspection Phase III Final Inspection <br /> Inspection By - '"�� Date �`- �` �U Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received nuary 31 ❑ July 1 &ReceivedJuly 31 <br /> R MyT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED 3 AMOUNT <br /> �3FEE <br /> LESS <br /> PRORATION ` �1 <br /> PLUS fir/ 'q` <br /> PENALTY <br /> OTHER <br /> OTHER <br /> -S <br /> Received <br /> Received by Date Receipt No. Permit No. IspuancEl Date Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />