Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION y , <br /> �y (For Non-Transferable, Revocable, Suspendable) PUMP&WELL (3// <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY r - <br /> ;t 1 <br /> Application is hereby madeto the San Joaquin Local Health District fora permit to construct and/or install the work herein described..This application is <br /> made in compliance w-iittht San oaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address �7�� /f ` 099A1_66 /�� City/Town <br /> Owner's"Name 't-A � - : TA Ausa.2 Phone -16% rT <br /> Address r City -- r <br /> Contractor's Name License# M/0 Business Phone' <br /> Contractor's Address 20 A-21 41h - Emergency Phone CA r <br /> Is Certificate of Workman's Compensation Insurance on Fife With SJLHD? YesNo <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ — r <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ©. PUMP INSTALLATION ❑ PUMP REPAIRS <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 f <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 r <br /> ❑ DISPOSAL ❑ OTHER Other Information {y <br /> ❑ GEOPHYSICAL. Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done l� <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> ` t 4 Describe Material and Procedure <br /> with an Joaquin Count <br /> I hereby certify that I have prepared this apphcatlon and that the work well be done m accordance 5 Jo q y <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 of the work for which 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 /> Contractor'shiring or sub-contracting signature certifies the following:"I 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 will I f7ora rouasp lion prior to grousing and a final inspectio 17 <br /> Signed X Title: Date: + <br /> (Draw Plot Plan on Reverse Side) t <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I y Gt <br /> Application-Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection ' ase III Final inspection I <br /> Inspection By Date Inspection B Date <br /> i00, <br /> j <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑-EACH ❑'January 1ceived By'January 31 ❑ July 1 i£Received By July 31 +ir <br /> REMIT f <br /> BILLING REMITTANCE` $ <br /> BASE EXPLANATION DATE DATE' REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> FEE is <br /> -LESS I <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER , <br /> Re eived by ate Receipt No. Permit No — -. Issuance Date - Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL'HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />