Laserfiche WebLink
FOR OFFICE.USE: APPLICATION <br /> {For Non-Transferable, Revocable,Suspendablt <br /> PILIA&E&WELL <br /> I M ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or install the work herein described.This app ation i <br /> made in compliance with San Joaquin C u Sty O dinance No.P1627d the-.rul sand regulations of the San Joaquin Local He Ith District. <br /> Exact Site Address City/Town <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name License#�-cac &Spl e s Phone <br /> Contractor's Address Emergency Pi <br /> Is Certificate of Workman's Compensati nsurance on File With SJLHD? . Yes hone No _ <br /> TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN ❑. RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATIIOON 11WELL ABANDONMENT 11 OTHER 1:1 PUMP INSTALLATIONPUMP REPAIR❑ <br /> REPLACEMENT Q- <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 /> ❑ IWUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC 0 DRIVEN Gauge of Casing <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> 13 CATHODIC PROTECTION 0 ROTARY Type of Grout <br /> ❑ DISPOSAL © OTHER Other Information <br /> ❑ GEOPHYSICAL f Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor — <br /> T.yyp �f Pump H.P. <br /> Ir <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 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. 1i <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:"t 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 will for a Grout Ins io I <br /> p prior to gr uting and a final in'pec <br /> Signed X <br /> Title: Date: <br /> (Draw.Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I bp�rr�e <br /> Application Accepted By Date1b-30—o'er <br /> Additional Comments: t <br /> Phase tl Grout Inspection r,MaIII Final Inspection <br /> Inspection By Date inspection By `` Date —17- <br /> s <br /> Fee Is Due: 11ANNUALLY C1PER UNIT 13PER SITE El FACH ❑ January 1&Received By January ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ A <br /> p - DATE DATE REMITTED MOUNT DUE CHECKED <br /> FEE �, 8 O AMOUNT <br /> L4 S <br /> LESS �7 <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER I <br /> OTHER �. <br /> 16 <br /> Received by Date Receipt No. Permit No. Iss ance qate Mailed Delivered <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P_O..BoK 2009 -STOCKTON,CA95201 <br />