Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (Far Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> COMPLETE IN TRIPLICATE WATER QUALITY <br /> /Application-is hereby made to he San Joaquin Local Health District fora permit to construct and/or install thework herein rdescribed.This application is <br /> / made in compliance with San Joaquin County Ordinance No. 1862 and the'rules and'regulations of the San oaquin Local Oealth District. <br /> Exact Site Addres -777 <br /> s City/To � � ,. <br /> ` �� <br /> Owner's Name ` �� " "" Phone" <br /> Address t rt _ City-7 <br /> Contractor's Name r '" "'� License*':' " ' r.. Business Phone <br /> Contractor's Address ";Ffl Is;1Il' to ' `` ; ' j,4t, . V'Emerg6ncy Phone <br />\S Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_ No 4) <br /> TYPE OF-WORK (CHECK): '-`�NEW WEEL w'DEEPEN ❑ -RECONDITION❑ -�-DESTRUCTIONS - <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 /> ❑ <br /> DOMESTIC/PUBLIC- ❑ DRIVEN _{Gauge of Casing') <br /> ❑ IRRIGATION % ❑ GRAVEL PACK Depth of Grout Seal <br /> 0 CATHODIC PROTECTION ❑ ROTARY r 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: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth t <br /> Describe Material n d ProcR ur <br /> I hereby certify that I have preps'ed 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." I <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." l <br /> t <br /> I will call fr a Grout In ion prior to grouting and a final inspection. <br /> + ' F <br /> igned Titl Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT <br /> �USE <br /> ' (ONLY <br /> PHASE I V�1`,r 1 <br /> � <br /> Application Accepted By ' t Date —1 <br /> Additional Comments: (.n. C <br /> Phase II Grout Inspection Phase III Final Inspection <br /> }Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT` ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 -Q July 1 8 Received By July 31- <br /> REMIT <br /> BILLING. , .. .__REMITTANCE $' ,BASE '"' t EXPLANATION `-' - AMOUNT DUE CHECKED - <br /> DATE DATES REMITTED AMOUNT <br /> FEELESS <br /> E <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> OTHER t J <br /> { <br /> OTHER <br /> Received by Dath Receipt No. — a — Permit No. _i, _-t Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 - <br />