Laserfiche WebLink
FOR OF:-iCE USE: t ,�; APPLICATION f <br /> (For Non-Transferable, Revocable,Sus endable) e PUMP 0 WELL J <br /> /• <br /> ENVIRONMENTAL HEALTH PERMIT ! <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <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 application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 nd the rules and regulations of the San Joagyj�nrI Health District. <br /> Exact Site Address W, fit. City/Town — <br /> Owner's Name A1 H C3 r is Phone <br /> Address City 7-1-7 <br /> Contractor's Name r License# Business Phone <br /> Contractor's Address A9 15 ` Emergency Phone r <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X _ No 1 <br /> TYPE OF WORK (CHECK): NEW WELL , DEEPEN ❑ RECONDITIONO DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT'❑ OTHER ❑ PUMP INSTALLATION ® PUMP REPAIR IJ <br /> i 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 ❑ 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 SealRInstal d By: '� <br /> C� <br /> i PUMP INSTALLATION: Contractor ,J % U• r <br /> Type of Pump <br /> PUMP REPLACEMENT: State Work Done_:c�t�j� �� �•– !'iL��f r �/�/ �� ,<� �,. � <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth (� <br /> Describe Material and Procedure V <br /> 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I w'It call for a Grout Inspection rl t tgr utin and a final inspection. <br /> Signed X ) , 1Cf' F r <br /> Date: - <br /> r (Draw Piot Plan on~Reverse Side) <br /> FOR DEPARTMENT USE ONLY a fri <br /> 1 PHASE I <br /> Application Accepted <br /> P y ate �- <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase II nal inspection <br /> Inspection By Date Inspection By s Jd Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July'31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE .A 4C <br /> O <br /> LESS `J <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER 7— <br /> Received by Date Receipt No. Permit No- nuance ate Mailetl Delivered <br /> I� APPLICANT—RETURN ALL COPIES TOS ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 F.HAZELTON AVE.,P,O,Boa 2009 STOCKTON,CA 95201 <br />