SU0008771 - Laserfiche WebLink

Home Browse Search

i Applications Will Be Processed When Submitted Property Completed.Be SureTO Sign ee Application. FOR OFFICE usE: APPLICATION f + ' (For Non-Transferable,Revocable,Suspendable) I ENVIRONMENTAL HEALTH PERMIT PUMP&WELL f (COMPLETE IN TRIPLICATE) WATER QUALITY 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 made in compliance with San Joaquin Cot�f rdi�nce .1862 and the rules and regulations of the San Joaquin Local Health District, Exact Site Address , I � City/Town Name13 Owner's Nau�r -- Address — Phone Contractor's Name City License Contractor's Address ff4 Business Phone ~— � Is Certificate Of Workman's Compensation Insurance on Fileith SJL File WHD? ergency Phone Yes 1 TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN❑ RECONDITION❑ No WELL CHLORINATIO WELL ABANDONMENT❑ OTHER ❑ PUfvIP INSTALLATION❑❑ PUMP REPAIR❑ REPLACEMENT Q DISTANCE TO NEAREST, Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit `J Property Line Private Domestic Well Other j TENDED USE Public Domestic Well TYPE OF WELL INDUSTRIAL ❑ CABLE TOOL ❑ DOMESTIC/PRIVATE Dia.of Well Excavation ❑ DRILLED Dia. Of Well Casing 13 DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing c I ❑ IRRIGATION ❑ GRAVEL PACK ❑ CATHODIC PROTECTION 13 ROTARY Depth Of Grout Seal 13DISPOSAL Type of Grout ❑ OTHER D GEOPHYSICAL Other Information 5 I PUMP INSTALLATION: Contractor Surface Seal nstalled By: Type of Pump H.P. f PUMP REPLACEMENT: (] State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL; Well Diameter 1 Approximate Depth Describe Material and Procedure I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state laws,and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this permit is issued, I shall employ persons subject to workman's compensation laws of California." f w R'Celt-f Grout Inspection prior to grouting and a final inspection. Signed Title; (Draw Piot Plan on Reverse Side) Date: =i PHASE FOR DEPARTMENT USE ONLY Application Accepted By I Additional Comments: Date� d ) Phase II Gro t inapet:lion inspection By Oats 111 Fin n tion Inspection 8 ate Fee Is Due:❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Janus 1 d Received eceived By January 31 ❑ July 1&Recelved By July 31 BASE EXPLANATION BILLING REMITTANCE- 5 REMIT DATE DATE REMITTED AMOUNT DUE CHECKED FEE; AMOUNT LESS -�PR OR ATION PLUS'`s PENALTY�- \ OTHER OTHER r ��rOV ` ++ceived by Date Retelpt Now - ti. Permit No. Issuance Date Mailed ��PLICAN7—RETUAN ALL COPIES TO: ENYIROMMENTAL HEALTH F4eAMIT/,SERVICER red 1641 E.tiALELTON AVE..P.O.Bo>,2049 PiRTON,CA 95201 --