Laserfiche WebLink
ApplicationsWill Be Processed When,Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> r <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) t�Q ,d,41 WATER QUALITY © Q3 - 3 q v—t ho <br /> 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 /> made in compliance <br /> �with S�an�Joaqui County Ordinance No. 1862 and the ries and egulations of the San Joa uin Loc I Health District. <br /> Exact Site Addressor c� - M City/Town <br /> s•leb"oh -- _ <br /> Owner's Name �• �� � Phone ArIZ 2-ZZ <br /> Address City_ T� <br /> Contractor's Name ' 'ki V 81M, License#_%702 X 3 Business Phone �743 = y2.2 - 3 d b 7 <br /> Contractor's Address O rel Emergency Phone x.23- �� 4&Is Certificate of Workman's Compensation Insura a on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL 111�- TDEEPEN ❑ RECONDITION❑ DESTRUCTION❑ p,, <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR El d� <br /> REPLACEMENT❑ s r l <br /> DISTANCE TO NEAREST: Septic Tank / Sewer Lines Pit Privy y <br /> i <br /> Sewage Disposal Field Cesspool/Seepage Pit Other - <br /> Property Line. Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑,-,, <br /> INDUSTRIAL ,-,,`` <br /> USTRIAL ,❑ CABLE TOOL Dia. of Well Excavation 5 <br /> a�pUMESTIC/PRIVATE DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing _ _ C C <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal / / <br /> 11 CATHODIC PROTECTION 11 ROTARY Type of Grout Ckc.!< -a r(} /T --C 11-1mI1k,0 d sa K dr <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 <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." # <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 /> I wil=for ut p 'or to grouting and a sinal Inspection. <br /> Signed X Title: 0 IL+LA N es, Date: v2 <br /> (Draw Plot Plan on Reverse Side) <br /> /OR/ZPARTME T USE ONLY <br /> PHASEI <br /> Application Accepted By °`^ 0_3 Date <br /> Additional Comments: ' A <br /> Phase II Grout Inspection Phase I11 Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Dile; ❑ ANNUALLY ❑ PER UNIT T$PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 1 <br /> REMIT <br /> EILLING REMITTANCE $ <br /> EASE EXPLANATION BAT£ DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS I v <br /> PRORATION /(l 0 S e< ko v+ <br /> PLUSPENALTY VO V eed, 'C-4 C C-///�I�VW I <br /> -'OTHER' vy <br /> OTHER <br /> GAS-dam <br /> Received by Date Receipt No Permit No. Issuance 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 />