Laserfiche WebLink
Applicatloiis Will Be Processed When Submitted Properly Completed.tBeSureToSignTheAppllcatlon. <br /> FOR OFFICE USE: APPLICATION <br /> FF <br /> (For Non-Transferable, Revocable, Suspendable) <br /> I. PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY b <br /> (COMPLETE IN TRIPLICATE) ; -rt <br /> t 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 /> I made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San JoaqW%Local;Health District: (J3 <br /> Exact Site Address <br /> ,y 1i ��-°L ® City/Town <br /> t } II <br /> Owner's Name ��'� ��r Phone <br /> Address City <br /> L Contractor's Name y � <br /> License# 7usiness Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With S HD? Yes _ No d <br /> TYPE OF WORK (CHECK): NEW WELL 11DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ 11VELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION;W PUMP REPAIR❑ (� <br /> t REPLACEMENT❑ _ <br /> li <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 /> tZ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> i <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing I <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed y: . <br /> PUMP INSTALLATION: Contractor— L1 _nZW1d4& <br /> Type of Pump H.P. 7 ✓ <br /> PUMP REPLACEMENT: IN State Work Done 4-- T 1 ' <br /> PUMP REPAIR: ❑ State Work Done <br /> r DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> l _ <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 Health District. <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 /> Il <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> r <br /> 1 ill call for a Grout In esti for t grouting and a final inspection. <br /> Signed Title: Date: <br /> li (Draw of Plan on Reverse Side) <br /> F R DE ARTMEN USE ONLY <br /> PHASE <br /> Application Accepted ByII' Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase HI Final Inspection <br /> f Inspection By Date <br /> ��ff Inspection By Date <br /> Fee Is Due: ElANNUALLYII, ❑ PER UNIT MPER SITE ❑ EACH ❑ January 1 &Received By January 31 El July 1 &Received By July 31 <br /> VREMIT <br /> SE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE DATE DATE REMITTED AMOUNT <br /> ii <br /> FEE <br /> LESS <br /> PRORATION X <br /> U ' _ <br /> PLUS <br /> PENALTY <br /> OTHER II ~✓r <br /> OTHER it <br /> Received by Date Receipt No Permit No. -1"Uan e'Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO:' ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 20D9 STOCKTON,CA 95201 <br />