Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed.Be Sure ToSignTheApplication. <br /> MFOR &FICE USE: APPLICATION ;. <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL I , <br /> 1f t <br /> ENVIRONMENTAL HEALTH PERMIT <br /> r I7 WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) a <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 applicationl5 <br /> made in compliance with San Joa uin Cou ty Ordinan 0 1862 and the rules and regulations of the San Jo in ocai Health District. <br /> Exact Site Address 1 City/Town <br /> lam* r <br /> Owner's Name Phone <br /> r <br /> Address City <br /> Contractor's Name # License# Business Phone <br /> Contractor's Address <br /> Emergency Phone 1 <br /> _ 1s Certificate of Workman's Compensation Innsurraan mon File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELLII� DEEPEN ❑ RECONDITION 1:1 DESTRUCTION❑ {{ <br /> WELL:CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 9�- �PUMP REPAIR❑ <br /> • REPLACEMENT❑, // s'' <br /> DISTANCE TO NEAREST: Septic Tank !�Q ~ Sewer Lines 15© Pit Privy <br /> `r + <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> r Property Line,40we Private Domestic Well 7JC Public Domestic Well <br /> ,INTENDED USE TYPE OF WELL ��.0���°✓ <br /> ❑ I�USTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> W DOMESTIC/PRIVATE ;.„ 13 DRILLED Dia. of Well Casing,, <br /> ,�, D�ESTiC/PUBLIC 11 DRIVEN Gauge of Casing j <br /> L'l IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal i <br /> �® <br /> � <br /> 13 CATHODIC PROTECTION W10—TARP ~Type of Grout -„ <br /> © DISPOSAL ❑ OTHER Other Information <br /> E] GEOPHYSICAL Surface Seal Installed By: f <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 /> Describe Material and Procedure <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 Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> _,e' is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich ich this his <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 1 will tail t a Grout Insp tion r to grouting and a final inspection. C� <br /> Title: Date: <br /> ' ! <br /> Signed X _ <br /> (Draw Plot Plan on Re erse Side} <br /> FOR DEPARTMENT USE ONLY �J I <br /> PHASE I y/B / p <br /> Date <br /> Application Accepted By IV t <br /> Additional Comments: i <br /> Pha a II G"utlction J _ J�Ph; ill Final Inspection <br /> Inspection By ate " Inspection B Dateew—d <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ElJanuary 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 /> di 0z T— <br /> FEE <br /> p{r LESS <br /> PRORATION <br /> PLUS <br /> G_— PENALTY <br /> a <br /> I <br /> OTHER <br /> OTHER <br /> 3 Permit No. Issuance Date Mailed elivered <br /> Received by .. Date ^'` Receipt No- <br /> f . _�,..� <br /> r, T' '1�- APPL4CANT�RETURN ALL COPIES TO:- ENVIAONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Bot 2009 STOCKTON,CA 9520 — <br />