Laserfiche WebLink
FOR'OPFICE USE: APPLI�ATI ON <br /> � 4 For Non-Transferable,"Revocable,Suspendablei ) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> ,(COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> r <br /> made in compliance with n Joaquin Coun y Or Gmance No Wes 1862 and the es anrigregulations of the San Joandin Lo I Health D• t. <br /> Exact Site Addresses % ' . _ City/Town � l <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name . Licertse.# Ly mousiness Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File Wit SJLHD? Yes — No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑, RECONDITION u DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑. OTHER ❑ PUMP INSTALLATION PUMP REPAIR <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 <br /> INTENDED USE TYPE OF;WELL (j <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 N <br /> ❑ DISPOSAL ❑ OTHER Other information <br /> ❑ GEOPHYSICAL urface Seal Installed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. _ <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMPA46PAPIR: IN State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> f <br /> Describe Material and Procedure <br /> _ I hereby certify that.ikhave 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 ceitifythat 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 wh ich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California.". <br /> I wil all for a Grout Inspeeti n nrpgr uti amend a final inspection. <br /> Signed X itie: . _' - _ Date: 13 <br /> (Draw Plot an on Reverse Side) <br /> FOR-DEPARTMENT USE ONLY <br /> PHASE <br /> i Application Accepted By es Date O INK., <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III F nspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Dile: 1:1. NNUALLY ❑ 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` DATE DATE REMITTED AMOUNT DUE CHECKED' <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY a <br /> OTHER <br /> x <br /> OTHER <br /> Received by Date Receipt No. Permit No: Issuance Date ...Mailed Delivered <br /> ` APPLICANT=RETURN ALI..COPIES TOi��'•..•ENVIRONMENTAL HEALTH PERMIT/SERVICES - -1801`ErHAZELTON AVE:,,P.O.BOX 2009 STOCKTON;CA 26201 _j^ <br />