Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTheApplication. <br /> FOR--FFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) I' <br /> PUMP&WI=LL - <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin Cou rdinance No. 113152,and the rules and regulations of the SanJoaquinLocal He District. <br /> k <br /> Exact Site Address 00 City/Town <br /> Owner's Name Phone <br /> AddressIty <br /> Contractor's Name r License#113-7)4 Business Phone._ <br /> Contractor's Address _C) Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With JLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <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 Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> IN 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 Q <br /> ❑ DISPOSAL ❑ OTHER Other Information C. <br /> ❑ GEOPHYSICAL Surface Seal Ins alled By: <br /> PUMP INSTALLATION: Contractor fi <br /> Type of Pump Htwith <br /> P <br /> PUMP REPLACEMENT: ❑ State Work Done / "" ' ' L <br /> State Work Done =rill.// —"'�"� 0 ] <br /> PUMP Appro <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accorquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance ofthe work for which this permit j <br /> is issued, l shall not employ any person in such manner as to become subject to workman's compensation laws of California." l <br /> Contractor's hiring or sub-contracting signature certifies the following:"1 certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I w I call for a Grout Inspecti n r' t gro Y95 and incl inspection. <br /> Signed tie: �r Date: f f <br /> (Draw Plot an on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI p <br /> Application Accepted By Date Q <br /> Additional Comments: <br /> Phase II Grout Inspection �f ; Ph I Final I pe on <br /> Inspection By Date 1 Inspection By ate 7 �1 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 $Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT ! <br /> CQ� <br /> FEE v <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> � I <br /> OTHER <br /> ii I <br /> OTHER' <br /> us. <br /> Received by Date l Receipt No. Permit No, Issuance Date Mailed Delivered i <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Sax 2009 STOCKTON,.CA 95201 <br />