Laserfiche WebLink
FOR OFFICE SE: f / ..ti APPLICATION 1`ti <br /> A -tror Non-Transferable, Revocable,Suspendable) PLIiVtP& WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) � WATER QUALITY <br /> Application is hereby made to the 5a Loc.�rI;t'9ealth 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. 1862 and the r les and regulations of the San Joaq In Lo I Health District. <br /> Exact Site Address City/Town <br /> Owner's Name GD Phone <br /> Address City. +� <br /> Contractor's Name V / e.I License#Lp'a 73..E _ Business Phone — (� <br /> Contractor's Address f Emergency Phone y <br /> Is Certificate of Workman's,-ompensation Insurance on File ith SJLHD? Yes X No <br /> TYPE OF WORK (CHECK)'. NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL, ABANDONMENT ❑ OTHER_ ❑ PUMP INSTALLATION ® PUMP REPAIR 13 <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 - <br /> ❑ INDUSTRIAL © CABLE TOOL Dia.of Well Excavation <br /> } DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing <br /> + ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> I' © IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: <br /> Contractor ptt}ev,� u., kt�a <br /> Type of Pump �u -s' 1. 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 /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, stateJlaws, 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 forwhich 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." 4" <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, l shall employ persons subject to workman's compensation laws of California." <br /> I ill call for a Grout I p c 'o o groulin nd a final inspecO, ,r. <br /> Signed rd` � � Title: 1--, <br /> (D <br /> Date: <br /> (Draw lot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By 1 DatCt e—a-,4M1 <br /> Additional Comments: <br /> Phase II Grout Inspection ! ase 1117i ' gtnspection <br /> Inspection ByDate <br /> - Q� Inspection By <br /> l i <br /> Fee Is Due: ❑ ANNUALLY © PER UNIT ❑ PER SITE 0 EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No, Permit No Assuance D to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO; ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAXELTON AVE.,P.o,Box 2009 STOCKTON.CA 95201 <br />