Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> ' (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLJCATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance wp San Joaquin Co nt Ordinance No. 1862 Ind the rules and rreg� ulati f_the San Joaquin Local Health District. <br /> Exact Site Address _GLtIJ C /Towr Z �L <br /> Owner's Name L d �.0 Phone ..,rf:,- z• � <br /> Address , 3. / City <br /> Contractor's Name _ r�C}t?�, License# / Business;Phone <br /> Contractor's Address <br /> > rgency Phone r. ,cc- .- .tas <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WEL'lLysk DEEPEN ❑ - 'RECONDITION❑ = DESTRUCTION❑ - <br /> WELL CHLORINATION ❑ WELL ABANDONMENT tOTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR ] <br /> REPLACEMENT❑ •}ii, <br /> DISTANCE TO NEAREST: Septic Tank, Sevier Lines r 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 i <br /> 1AI INDUSTRIAL - ❑ CABLE TOOL-;� _ Dia- 01.Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge-of Casing - <br /> � <br /> ,I (. r <br /> ❑ IRRIGATION Itl� <br /> sde GRAVEL PACK Depth of Grout Seal f <br /> ❑ CATHODIC PROTECTION la ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL r Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump- <br /> KIP. , <br /> PUMP REPLACEMENT: ❑ State Work Donef" - <br /> PUMP REPAIR: ❑ State Work Done 1 ' <br /> DESTRUCTION OF WELL: } Well Diameter Approximate Depth' <br /> Describe Material and Procedure I ) <br /> 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,Joagbin Local Health District. �. <br /> Home owner or licensed agent's signature certifies the tgllowing:"I certify that in the pdHorriianceof the work for which this permit <br /> is issued, l;shall t.employ.anyt,person,i�rlsuch'manner as to;pedprpeyikiject to workman's compensation laws of California." <br /> 'Contractors hirthg or sub-contracting signaturwcertifies the following::"I certify that in the performance o.f the work for:which this ' t' <br /> - permit is issued;1,shall employ persons subject to workman's cornpensMion'laws of-California." <br /> I wl call for a Grout In etion prior t grouting and a fine-inspection 14 yy <br /> Signed X t Title. A ` Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY ~# <br /> PHASE I <br /> Application Accepted By Date <br /> : i <br /> Additional Commentst: <br /> 1 e rout)nspection Phase til Final Inspection <br /> Inspection By—* <br /> y ry Date -� ' �.�J `Ins"action By-i", _� Date <br /> __ 71t <br /> Fee IS Due: ❑'ANNUALLY' _ 11 PER UNIT ❑'PER SITE'' ❑ EACH - ❑ January 1 &Rece+Gad By Janoary 31 ❑ July 1 &Received 9y July 3 - <br /> c BILLING REMITTANCE a $ Al <br /> REMIT <br /> BASE EXPLANATION �y�.., " r AMOUNT DUE CHECKED <br /> DATE DATE _ �/3REMITTED,r' AMOUNT 'y <br /> ` 3 - <br /> J <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS 7 72 <br /> PENALTY <br /> OTHER -- - <br /> OTHER <br /> i <br /> 3 l3 -[ 1 <br /> Received by. Date _ Receipt No.. Permit No. Issuance Date Mailed Delivered. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 11601 E.HAZELTON AVE-,P.O.Box 2009 STOCKTON,CA 95201 <br />