Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> R- (For Non-Transferable, Revocable,Suspendable) <br /> PUMA&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY. <br /> Application is hereby madetotheSan Joaquin Local Health District.fora permit to construct and/or install thework herein described.This application is <br /> made in compliance with San.loaqui oun y Ordinance No. f8 a the rules and regulations of the San oaqui'n L cal Health District, <br /> Exact Site Address t�) IC1' City/Town L <br /> Owner's Name }z Phone W <br /> Address UK. r , <br /> City' <br /> Contractor's Name r tJ'�-J. License# Business Phone <br /> Contractor's Address Emergency Ph e �cc-G • <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes o No �. <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR L'9"' <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 /> ® DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC v ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal i <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> Cl DISPOSAL ❑ OTHER Other Information ) <br /> 11 GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. v) r <br /> PUMP REPLACEMENT: ❑ State Work Done ' <br /> PUMP REPAIR., A'State Work Done Q12 r <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby certify that 1 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 /> 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's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws o California." <br /> I will all for a,Grou S ec. prior to grouting and a final inspection :. <br /> Signed X <br /> Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE L � ,� � <br /> Application Accepted By w Date. _C_ � <br /> Additional Comments: <br /> Phase If Grout Inspection 44x— <br /> h I Final Inspection <br /> Inspection By Date f <br /> Inspection Date <br /> Fee Is Due: ❑ ANNUAE_LY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January ' eceived By January 31 '❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE REMIT ' <br /> i BASE EXPLANATION $ AMDUNT DUE CHECKED <br /> DATE DATE REMITTED. <br /> AMOUNT <br /> FEE 5 <br /> LA'S <br /> LESS i <br /> PRORATION ' <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER µ „� <br /> Received by Date Receipt No, Permit No. —• - Issuance Date. Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON.CA 95201-' <br />