Laserfiche WebLink
Fr'' OFF':�E USE: APPLICATION J <br /> • (For Non-Transferable, Revocable, SuspendaL <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> Al <br /> ,,!' war R QUALITY <br /> (COMPLETE IN TRIPLICATE) z���� • f � <br /> Application is hereby made to the San Joaquin Local Health Distrf lfora Prnit to construct and/or install the work herein described.This application is <br /> made in ce vyith S JE <br /> Joaqu n C y 'nan No: 62 and the rules andre uiations of the San aquin Local H th District. <br /> M Exact S o ' ' I.-aLfp� City/Town <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name License /Business Phone, �o C- <br /> Contractor's Address Emergency Phonef7✓�v�P ..___ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_ � No <br /> TYPE OF WORK (CHECK): NEW WELL- DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT © OTHER ❑ PUMP. INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank l/)C Sewer Lines Pit Privy <br /> Field Cesspool/$eep � <br /> ag .Pjl. ' �'� Other _ <br /> Property Lib Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL , C <br /> ❑ INDUSTRIAL ABLE TOOL Dia. of Well Excavation <br /> -DOMESTIC/PRIVATE ❑ DRILLED Dia. of We Casing r <br /> ❑ DOMESTIC/PUBLiC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout K <br /> ❑ DISPOSAL ❑ OTHER Other information• 1 <br /> ❑ GEOPHYSI_C_AL __ µ _...,. . Surface Seat Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump A � ' <br /> '' H.P. <br /> PUMP REPLACEMENT: ❑ State Work Dona <br /> PUMP REPAIR: ❑ State Work Done <br /> I _ <br /> DESTRUCTION OF WELL: Well Diameter Approxunate:Depth ` <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accorda ce with San Joaquin County <br /> ordinances,state laws. and rules and regulations of the San Joaquin Local Heal th District. l <br /> Homeowner or licensed agent's signature certifies the following'."I certify that in the performanceo R Work forv&ch this permit y <br /> is issued, 1 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 will c I for a Groul In ection prior to grodting.and a tidal Inspection. <br /> Signed X <br /> Title: 0--a.U:!M Dale: �J <br /> (Draw.Plot Plan on Reverse Side) <br /> i ! FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> &A I O <br /> Application Accepted By !� Date <br /> Additional Comments: <br /> Ph It Grou nspectton P Lase III Final Inspection,, <br /> 011.1' a Inspection B , 43`x'' �%�t Date <br /> Inspection By-_ Date P Y t <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT I ❑ PER SITE ❑ EACH ❑ January I. 5 Received By January 31 ❑ July 1 &Received By July 3t <br /> REMIT <br /> ' BASE. EXPLANATION.... BILLING REMITTANCE � S' 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 Dale Receipt No. Permit No. issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE..P.O.Boa 2009 STOCKTON.CA 95201 <br />