Laserfiche WebLink
I Applications Will Be Processed When Submitted Nropeny L.ompleavu. o- -­ •- i <br /> APPLICATI6I4. .T <br /> FOR OFFICE USE: .e .01 <br /> .,. _ --(For Non-Transferable, Revocable, Suspendable) PUMP&WELD <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Districtforapermittoconstructand/orinstalltheworkhereindescribed.Thisapplication ls <br /> Application is hereby made to the San Joaquin Local Health <br /> Ordinance No. 1862 nd the rules and regulations of the San Joaquin Local Health District. <br /> made in compliance with San Joaquin County <br /> City/Town ` <br /> Exact Site Address <br /> ' Phone <br /> Owner's Name City <br /> Address �� <br /> License#� � Business Phone <br /> Contractor's Name AA =- i <br /> i� Emergency Phone <br /> Contractor's Address ;y� No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 1 <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATIONMP <br /> ❑ WELL ABANDONMENT ❑ OTHER 13PUMP INSTALLATION UMP REPAIR❑ <br /> 11 <br /> r REPLACEMENT& <br /> Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Cess ool/Seepage Pit Other <br /> Sewage Disposal Field p <br /> Property Line-tr Q Private Domestic Well Public Domestic Well <br /> r INTENDED USE <br /> ---TYPE OF WELL <br /> k ❑ CABLE TOOL Dia. of Well Excavation <br /> - 11IN STRIAE -� <br /> lOMESTIC/PRIVATE 11DRILLED_-' � ' Dia. of Well Casing <br /> P-1511 DRIVEN Gauge of Casing <br /> 11DOMESTIC/PUBLIC <br /> 11 IRRIGATION <br /> 11 GRAVEL PACK �' *. Depth of Grout Seal <br /> ❑ CATHODIC PROTECTIdN C1 ROTARY Type of Grout <br /> ❑ DISPOSAL i/ ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Turf ce S al Installed By: <br /> PUMP INSTALLATION: Contractor CQ <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL <br /> Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> E s_• <br /> I I hereby certify that 1'.h-ave prepared this application and that the work will be done in accordance with San Joaquin oun y <br /> ordinances, state laws, arid,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 for which this per ` <br /> is issued, I shall not employ any p <br /> erson in such manner as to become subject to workman's compensation laws of California." <br /> y that in the performance of the work for which this <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certif <br /> i. permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I w' call to rout <br /> iinss ctiga on prior to grouting and a final inspection. i <br /> C. 4I Title: <br /> Date: <br /> Signed X f <br /> (Draw Plot Plan on Reverse Side) <br /> + FOR DEPARTMENT USE ONLY <br /> PHASE I '� J Date r zL <br /> IW <br /> FApplication Accepted By e <br /> Additional Comments: a '� ` III Final I pectian <br /> t Pha a 11 Grout Inspection #` <br /> Date <br /> Inspection B .a.>y,�7ate -/� <br /> Inspection By11 ' <br /> k Fee IS Due:.❑ ANNUALLY PER UNIT- ❑ PER SIDE El EACH ❑'January 1 &'R ceived By January 31 ❑ July 1 &Received EB�ylTuly 31 <br /> % �` <br /> ON BILLING' REMITTANCE $ AMOUNT DUE CHECKED <br /> EXPLANATI <br /> I BASE DATE f /"NATE REMITTED AMOUNT <br /> FEE <br /> f <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY 5 Z'lov <br /> r <br /> OTHER <br /> a <br /> OTHER <br /> Received by Date Receipt No o, 1 suance ate Mailed Deli red <br /> , APPLICANT—RETURN ALL COPIES 70: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P:O.Box 2009 STOCKTON,CA 9 <br />