Laserfiche WebLink
,Applications Will Be Ffi eased When Subri ftted Pr re T <br /> r r openly Completed.Be Sure TO Sign The Applcatiorr. <br /> FOR,Q;=1=t "us>:;� .� APPLICATION <br /> I <br /> s•'' ^, (for Non-Transfarabie,Revocable,Suapert&W#)` PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT W <br /> WLETE IN TRIPLICATE) WATER>QUAIITY <br /> r.r{,ication is'herebymadetotheSan Joaquin Local Health Districtforapermit toconstruct andlorinstalithework herein described.This application is <br /> madeg n.eLpliance with San Joaquin County Ordinance No. 1883 and the rules and regulations of the San Joaquin Local Health District. <br /> Exabt Site Address-••-.� ......_3 �..�/Y'.e%iL''�.d City/Town._-_L�,, f <br /> Owner's Name G� y <br /> �,_ ," Phone <br /> -� <br /> Address + / LJ! <br /> Contractor's Name !�,/ � _...__ _ City��, ,S � <br /> Lioense _ Business Phone- - <br /> Contractor's Add0. mergency Phone --:3-" 460'r' <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ........... No <br /> TYPE OF WORK(CHECK): •NEW WELL 0-----DEEPEN ❑ RECONDITION❑ DESTRUCTIONO <br /> WELL CHLORINATION© WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION G ' PUMP REPAIR r_vJ <br /> REPLACEMENT❑ ' 1�1nVi <br /> DISTANCE TO NEAREST: Septic Tank + Sewer Lines Pit Privy V <br /> Sewage Disposal Field _.. Cesspool/Seepage Pit _ Other <br /> Prti rt Line ✓' ..__ <br /> party Private Domestic Well Public Domestic Well <br /> INTENDED USE '' TYPE OF WELL <br /> ❑,�, INDUSTRIAL ❑ CA13LE TOOL Dia.of Well Excavation <br /> +sDVMESTIVPRIVATE ❑ DRILLED Dia.of Well Casing ..._... Jfr __...._.........___.... ' <br /> ❑ DOMESTIC/PUSLIC n; ❑ DRIVEN Gauge of Casing 1 _....__._.......----. r <br /> ❑ IRRIGATION " ❑ GRAVEL PACK Depth of Grout Seal �+ <br /> ❑ CATHODIC PROTECTION � ARATARY Type Of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICALurface Seal Installed 8 ' <br /> PUMP INSTALLATION: W- <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ! ❑ Stats Work Done ...._... <br /> r "I REPAIR: ❑ State Work Done <br /> RUCTION OF WELL: ^ Well Diameter -_ Approximate depth . <br /> 4 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 fallowing:"I certifythat in the pdrfonnance 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 hiringor sub-contractl signature certifies the following: certify p # y t <br /> � g np:"i cern that in the performance of tris work for which lois a; <br /> permit is issued,I shall employ persons subject to workman's compensation laws of California." � <br /> I will call for a Grout inspection or to groun and a final inspection. <br /> Signed X , �,@ ,r ��a ✓w•. Tills: -ati� _ 3 <br /> 71 Plot Ptan on Reverse Side) <br /> PHASE i <br /> FOR DEPARTMENT USE.ONLY <br /> �,,.-- <br /> Application Accepted By <br /> Date . <br /> Additional Comments; <br /> Phe 11 Grout I ri j 4li Final fnspection / <br /> inspection By �1 ane-M. l '�.� -7 Inspection B j_ __.._- Date <br /> Fee Is Due:❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January?a Aemc d ey.aenunry 3 ❑July 1&Aeeeived By July 31 � <br /> ...__._._..._....,..__....:._..._._,._.._. .._ ....,,.____... ........;__.... ..._..._..............._... <br /> REMIT <br /> BASE ExrKANA71t7N ± SiLLING REMITTANCE S AMOUNT OUE CHECKED <br /> DATE DATE REM07TEO AMOUNT <br /> PEE <br /> I Ess ' `{ <br /> PRORATION l <br /> PLUS <br /> PENAL TY <br /> OTHER <br /> OTHER <br /> 0 <br /> .-- . , <br /> Atceived Osie. r Rec+erpt No. Permit No. i8auina8 date Mailed Deiiverwf, •,, <br /> A"LICANT--RETURN ALL COPIES TO: EW4 tYAL HMTH P£AtaIT>sM#CES 1801 E HAZELTOX AYE-P.O.Bac 300a STOCKTCN,CJS s3iot <br />