Laserfiche WebLink
M ApplicationsWill BeProcessedWhenSubmitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> 4_ (For Non-Transferable, Revocable, Suspendable) <br /> b ENVIRONMENTAL HEALTH PERMIT PUMP&WELL 1 <br /> (COMPLETE IN TRIPLICATE) ,.I� � � WRYER'QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the ork herein described.This application is <br /> made in compliance wi San Joaquin y Ordinance N . 1 2 attd the r s Znre gul do Sof <br /> Exact <br /> t Joaquin cal Hea th D trict. <br /> Exact Site , WIWI <br /> Address - Ql <br /> Owner's Name 7- Phone 36,9 77 <br /> Address City <br /> Contractor's Name License Business Phone '5�15- I � <br /> Contractor's Address S&DEmerg ency Phone 6SS-i-27/ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes b__11 No <br /> TYPE OF WORK (CHECK): NEW WELL.W" 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 �f <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation C1?1? <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing <br /> 16 <br /> r/ <br /> ,�3 DOMESTIC/PUBLIC ❑ RIVEN Gauge of Casing <br /> W IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION 310TARY Type of Grout /I0neP l <br /> ❑ DISPOSAL ElOTHER Other Information i <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done x <br /> PUMP REPAIR: ❑ State Work Done a <br /> DESTRUCTION OF WELL. Well Diameter <br /> 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 /> 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 of California," <br /> I w'I call fora GroutAlection prio to gro ting a final inspection. /� <br /> Signed X Date: �7 l7 <br /> (Draw Plot Plan on Reverse Side) <br /> j R rZ CL; :;,a mo IEE FO EPART NT USE ONLY <br /> PHASE <br /> Application Accepted By Date �� <br /> -76 <br /> Additional Comments: <br /> Phase II Grout Inspection hos�HF!nal Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 19 PER SITE ❑ EACH ❑ January 1 &Rece Sy January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER < <br /> 4 �Z77 l 7,Z <br /> 1 <br /> Received by Dat& Recei t No. Permit No. Issuarice Date Mailed Delivered ./ <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 85201 I/ <br /> f <br />