Laserfiche WebLink
ApWj6Ations Will Be Processed W ed Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: D EC 3 19q� APPLICATION <br /> SAN or Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> "E� T �1IV L(," IIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) �'��+`tj�, WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install thework herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 862 and AI e-ies and regulations of the San Joaquin L cal Health District. <br /> Exact Site Address a- <br /> City/Town � lfll/ <br /> Owner's Name �/�y <br /> Address rri Phone <br /> Contractor's Name ""� S�. City <br /> License# 02 Business Phono -22-o- <br /> Contractor's Address `�1, Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes JC1 `I <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ No <br /> RECONDITION LJ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION N PUMP REPAIR 11 <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines <br /> Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit <br /> PropertyOther Line Private Domestic Well <br /> Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL <br /> �DOMESTIC/PRIVATE 13 DRILLED <br /> of Well Excavation <br /> DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY <br /> 11DISPOSAL Type of Grout <br /> ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL <br /> urface Seal Installed By: <br /> PUMP INSTALLATION: Contractor aSf4_ <br /> Type of Pump H.P. J f <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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 /> 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 /> 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 wall for a U.. ipection prior to grouting and a final inspection. <br /> Signed X Title: ,QL) �/ � <br /> Date: <br /> (Draw Plot Plan on Reverse Side) <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> {gyp <br /> Application Accepted By <br /> Additional Comments: Datey+ <br /> Phase II Grout Inspection a I al Inspectio <br /> Inspection By Date Inspection <br /> Dat <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH <br /> ❑ January 1 eceived By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCEREMIT <br /> DATE REMITTED <br /> DATE $ AMOUNT DUE CHECKED <br /> FEE AMOUNT <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> "M 13-1 <br /> Received by Da a Receipt No. Permit No- <br /> APPLICANT—RETURN ALL COPIES TO., ENVIRONMENTAL HEALTH PERMIT/SERVICESIssuance Date Mailed Delivered <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />