Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> FOR FFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San J^oyagyyuin Countnt rdi nce o. 1992 and a rules and regulations of the San Joe uin Local H Ith District. <br /> Exact Site Address �J�/"L� —/a� �' / City/Town I - �'¢� <br /> Owner's NameT�y✓l� 21' ` "�' " �r'� Phone <br /> AddressCity <br /> Contractor's Name T - -5 License C24, `-"-" Business Phone_ - <br /> Contractor's Address Emergency Phone - <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL m-'� DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 11 OTHER ❑ PUMP INSTALLATION PUMP REPAIR El ` <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines X44!2 et Pit Privy <br /> Sewage Disposal Field Cesapoel/Seepage Pit /T Other <br /> Property Lina I'Private Domestic Well Public Domestic Well - - <br /> INTENDED USE TYPE OF WELL <br /> ❑,--,, INDUSTRIAL 9 CABLE TOOL Dia. of Well Excavation <br /> akDOMESTIC/PRIVATE RILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing e_� <br /> I]kfARIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> 11CATHODIC PROTECTION ❑ ROTARY Type of Grout / f <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 11GEOPHYSICAL Surfac Seal Ins}all�By <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 2ze�— H.P. <br /> d <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done r <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth 4 <br /> Describe Material and Procedure Y <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County yN <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Cyt <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 subcontracting signature certifies the following:"I certify that in the performance of the work forwhichthis <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California:' <br /> I it for a Grout Inspection prior to grouting and a final inspection. L -i <br /> Signed Jc( Ti <br /> le: Date: <br /> (Draw Plot Plan on Revers ide) <br /> q FOR DEPARTMENT USE ONLY <br /> PHASE I // Date d <br /> Application Accepted By mac✓ <br /> Additional Comments: If Fin spectio <br /> Phas If tpo�ut Inspection �j d <br /> 7 �r4rA� dd6rar Date�'�' Inspection By Date <br /> Inspection By <br /> I <br /> Fee Is Due: [IAN DALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January ❑ July 1 &Receiv REMITBy uly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED p AMOUNT <br /> �p <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS — <br /> PENALTY <br /> OTHER <br /> OTHER <br /> nate Receipt No. Pann it No. Issuance Lana Mauled Dal d <br />