Laserfiche WebLink
w, nINTRIPLICATE) <br /> ppcattOne Will 8a ProceseW When Submitted Propedy Completed.Be Sure To Sign The Application. ..APPLICATION(For Noh-Transferable,Revocable,SuspenCable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> MPLETE WATER QUALITY <br /> plication 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 Joaqu' Can Ord�3Rce No. t86 a d the rule nd reg lations of the San Joe . o al Health District, <br /> Exact Site Address � �'� a r <br /> A <br /> lt}4� City/Town <br /> Owner's Name g&12 'rI Phone <br /> Address <br /> City— <br /> Contractor's <br /> Name License.# /y3.7.�3 Business Phone '�'�' '7 <br /> Contractor's Address 6d .Emergency Phone (' <br /> Is Certificate of Workman's Compensation Insurance on Fit ith SJLF Yes Y No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEP ❑ RECONDITION❑"`DESTRUCTION❑ CrJ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR 19 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field �sspool/Seepage Pit T— Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE '4. TYPE OF WELLI <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia.of Well Excavation <br /> 1C DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing I <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN _ t <br /> Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grou Seal < t <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ' <br /> ❑ DISPOSAL 11] OTHER Other Information I <br /> f <br /> 13 GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION; Contractor MAIZ <br /> C' <br /> Type of Pump- _ S�il�Aee• _i(_ H.P.. <br /> PUMP REPLACEMENT: P-State Work Done �- <br /> MP REPAIR: V State Work Done <br /> TRUCTION OF WELL: Well Diameter Approximate Depth f t <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 HealthDistrict. <br /> Home owner 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 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 /> I wi! call for a Grout Inspecti n If to r ,Inn and a al inspection. , <br /> e <br /> Signed •� file: P41ms Date: 1 <br /> 40 (Draw Plot an on Reverse Side) - _ <br /> EOR D PARTME USE ONLY 1 - <br /> PHASE I r ' <br /> Application Accepted Sy Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Pha I �id�.caalll Inspection cy <br /> Inspection By x Date Inspection By/ `��F `6 �� Date G ���o •$'C� <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE t <br /> .❑EACH ❑ January 1 8 Recelved By January 31- ❑ July 1 &Received By July 31 <br /> BILLING 'REMITTANCE S REMIT <br /> BASE E%PLANATION DATE DATE REMITTEDAMOUNT DUE CHECKED f <br /> t AMOUNT <br /> FEE <br /> LESS <br /> PRORATION + ' <br /> •PLUS - :ta :.x• <br /> +. +PENALTY ` 4 <br /> OTHER <br /> OTHER <br /> S !R �3 Z <br /> =�ecoived by w:7-ua1e,' _ .Receipt No. .,:�^^" Pennit Na. lieu ce Oete Mellbd Delivbred <br /> LL f <br /> APPLICANT—RETURN ACOPIES TO: ENwRONMEWA[HEALTH PERMIT/SERVICES' i8a1 E.HAZELTONAIni:,A.'O bx IIy`SxOCKTON_�CA sm S �T <br />