Laserfiche WebLink
FOR OFFICE USE: , -N7 APPL"i AtION " <br /> &Ali,t`ia 34 ,Pr Non-Transferable,Revocable,Suspendable; <br /> PUMP& 711EI_L <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY.. <br /> Application is hereby madeto the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 18 and the rules and regulations of the San Joaquin, oca Healthstric�t/. � <br /> Exact Site Address D S City/Town cs� /rTP <br /> Owner's Name cuCo4 f - Phone <br /> �..� /� _ <br /> I Address q- Z � City— H2ga cg l r - <br /> Contractor's Name2n)xn License#-7.__._.._t Business Phone 444Y <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on !e With SJLHD? YesNo <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ Cd <br /> ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION® PUMP REPAIR❑ <br /> WELL CHLORINATION �} <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 j <br /> I <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia.of Well Casing I <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> r <br /> ® IRRIGATION E'GRAVEL PACK Depth of Grout Seal <br /> ❑"CATHODIC PROTECTION ❑_ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL SurfaceS��Installed By: f <br /> PUMP INSTALLATION: Contractor 1 1 <br /> Type of Pump 1 H.P. <br /> PUMP REPLACEMENT: DrState Work Done " 4-1 X 1& <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth. ; <br /> Describe Material and Procedure i <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Q i <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 /> 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 Insp c n r o routing d a final Inspection. <br /> Signed X Title: +"� Datec <br /> (Draw Iot,.Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By """" O Date�"S"$� <br /> Additional Comments: <br /> Phase 11 Grout Inspection ase III Final inspection <br /> Inspection By Date Inspection BY144 Date <br /> Feels Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑.EACH ❑ January.1 &Received By January 31 ❑`July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE " $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED . <br /> AMOUNT <br /> FEE <br /> LESS . <br /> PRORATION 6 <br /> PLUSPENALTY h r 4 f <br /> 1 / <br /> OTHER <br /> OTHER <br /> 5 <br /> Received by Date Receipt No. . Permit No. uano OWL, Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO. ENVIRONMENTAL HEALTH PERMIT/SERVICES - .1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA,95201 <br />