Laserfiche WebLink
T Applications Will Be Processed When Submitted Properly Completed. B 15 relT_olyMnTRY1ioI,a_vn� � <br /> FOR OFFICE USE: APPLICATION U LU � �i <br /> (For Non-Transferable, Revocable, Suspen f I I 1tyMP&WALL <br /> 4 ENWRONMENTAL HEALTH PERMIT <br /> JUL .7 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY SAN JO QUIN LOCAL <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instft-fij hof,�Idif�ed.This application is <br /> made in compliance wi rl uin Cou ty ordinance 7 62 and�be rules and regulations of the San Joaquin LocaC�l H_eaallth Strict. <br /> Exact Site Address City/Town <br /> Phone '771J <br /> Owner's Nam <br /> Address City <br /> V 7 License# BU_wi ess P o AL <br /> Contractor's Name <br /> Contractor's Address r Emergency Phone <br /> Is Certificate of Workman's C fip neatio� fur nee lr�Fi it SJLHD? Yes No <br /> TYPE OF WORK {CHECK): NEW WELL <br /> DEEPEN 13 RECONDITION 13DESTRUCTION❑ O <br /> WELL CHLORINATION 13WELL ABANDONMENT 11OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ <br /> 1 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other ` 1 <br /> Property Line Private Domestic Weil Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> 11 <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 7 <br /> ❑ DOMESTIC/PRIVATE <br /> ❑ 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 <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> I" PUMP INSTALLATION: Contractor <br /> f Type of Pump H.P. <br /> I El State Work Done <br /> PUMP REPLACEMENT: <br /> PUMP REPAIR: Zkgiate Work Don <br /> DESTRUCTION OF WELL: Well Diameter— Approximate Depth <br /> Describe Material and Procedure <br /> r <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 /> 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 /> f Contracto ' Iring or sub-contracting signature certifies the following:"I ertify that in the performance of the work for which this <br /> i d I sh em oy persons subject to workman's compe tion laws of California." <br /> I rout pect n prior to grouting and a final 1 e f �� <br /> Signed <br /> Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> f <br /> PHASE ] <br /> Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phase 11 Grout inspection Phase 111 Final Inspection <br /> f Inspection By Date Inspection By Date <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT IZ-PER SITE ElEACH ❑ January 1 &Received By January 31 C1 July 1 &ReceiveRdEByl July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> f <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 4 <br /> Received by <br /> Date Receipt No. Permit o- ti Issuance Date Mailed Delivered <br /> �.: _ APPLICANT—RETURN ALL COPIES-TO:,ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95 <br />