Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To�Sign The Application. <br /> FOR OFFICE USE: - APPLICATION .f Jam,+ <br /> •: Id {For Non-transferable, Revocable,5uspendable} I� PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT IT�Am <br /> WATER QUALITY WO—C 646n e"'...040 <br /> (COMPLETE IN TRIPLICATE) 44-4 WWV C-AVV4-1 I'D 9**4 'JotV AMW <br /> Application is hereby made to the San Joaquin Local Hl?alth District fora perm it to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1$62 and the rules and regulations of the San Joaquuin, �occaRHealth District. <br /> Exact Site Address ato 7 05PId City/Town <br /> Owner's Name ' Phone <br /> Address C0 r,G - ,J. t City 611 <br /> Contractor's Name -License# /9,3-731S--Business Phone'. . <br /> Contractor's Address Emergency.Phone <br /> Is Certificate of Workman's Compensation Insurance on File ith SJLHD? Yes No v <br /> TYPE OF WORK (CHECK): NEW WELL❑" DEEPENEI-' RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION. PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer tines 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 /> RS DOMESTIC/PRIVATE ❑ 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 t Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 6' iT ate. <br /> 74> <br /> Type of Pump � H.P. <br /> PUMP REPLACEMENT: I0 State Work Done p 7Azrr Ayn® "� �� ��°� * �'r�•"��� <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter. Approximate Depth <br /> Describe Material and Procedure (0 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County `: 1 <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 will call for a Grout Inspection p for to ro liand final inspection. ? <br /> Signed.Xf�73 iMe: �v"" Date: <br /> (Draw Plot Ian on Reverse Side) <br /> FOR PARTMENT USE ONLY <br /> PHA5E f L�� <br /> Application Accepted By �"' Date <br /> Additional Comments: <br /> Phase Ii Grout Inspection Phase I Final I spection <br /> Inspection By Date /v Inspection.By Date <br /> Fee IS Due: ❑ ANNUALLY ❑'PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> J: REMIT <br /> BASE EXPLANATION BILLING REMITTANCE,..; $ AMOUNT DUE CHECKED <br /> C "'DATE DATE REMITTED AMOUNT <br /> FEE L''J l <br /> LESS ' <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date _ Recespt.No. .. Permit No. 14suance Ddte .Mailed Delivered _ <br />� APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9S201 <br />