Laserfiche WebLink
rr1J}/nl.Glryna rr rre OC rr LF1-"*CU rr-1rC11 QUiq I111MU F-IUPCIry S-UHIPFUMU. De OUre to Sign one Jippllcarlon. <br /> FOR OFFICE USE: APPLICATION ' <br /> ("N.-or-or Non-Transferable, Revocable, Suspendable(` ) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <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 /> made in compliance with San Joaquin County Ordinance lJo. 186 and the rules and regulations of the San Joaquin Local Health istrict. <br /> Exact Site Address .777L5; I�SL�cZ City/Town f' =� <br /> Owner's Name. Phone / <br /> �c - 9 6_6 V8 <br /> Address f` City_ /ZPyIr�/?rf �G <br /> Contractor's Name License# 0294 Business Phone ^—// <br /> Contractor's Address �� Emergency Phone <br /> Is Certificate of Workman's CompensationIn urance on File With SJLHD? Yes X.— No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy ' <br /> Sewage Disposal Field 1/� '>�' Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL <br /> y� CABLE TOOL Dia, of Well Excavation <br /> y� <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing J 6v <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout . T! <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: . <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H P <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. <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit V I <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 /> 1 will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X toZAQ�• Title: Date: <br /> I <br /> (Draw Pp Plan on Reverse Side) I <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date <br /> Additional Comments: <br /> hase 11 ro spection Pha a I. Final Inspection <br /> Inspection By pate Inspection By _ Date �Z 3 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 f <br /> REMIT <br /> BILLING REMITTANCE $ j <br /> BASE EXPLANATION AMOUNT DUE CHE=CKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEES- <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> -Tyl <br /> Received by Dae Receipt No. Permit No. issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2" STOCKTON,CA 95201 i <br />