Laserfiche WebLink
Applications Will Be ProcessedWhen Submitted ProperlyGompletea.esesure 1osign Inesppnc>auvn. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) ` <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install thewo herein described.This application is <br /> r made in compliance with San Joaquin Cou ty Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address ��-� �/� City/Town <br /> Owner's Name Phone <br /> Address City Z,-_J ?7 <br /> Contractor's Name License 1_?3 Business Phone����J <br /> Contractor's Address -Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD?, Yes No 4� <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 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 /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ,^ <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEL Gauge of Casing <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 By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. _ <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: tate Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <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 /> 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." C <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,f shall-employ'persons subject to workman's compensation laws of California." <br /> I wcall f r a Grout Ins ction prior to grouting and a�-fiifnal inspection. <br /> Signed X titleDale: <br /> (Draw Plot Plan on Revere Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE C <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase I 1 i I Inspection <br /> Inspection By Date inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT © PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> /( DATE DATE REMITTED AMOUNT <br /> FEE ��~GYM <br /> LESS <br /> PRORATION <br /> PLUS Q� <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITYSERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />