Laserfiche WebLink
T Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) 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 the work herein described.This application is <br /> made in compliance with San,�Jgaquin County Ordinance No. 1862 and the rules and regulations of the}San Joaquin/L cal Health District. <br /> ,' Exact Site Address ��� ''{� L e V City/Town /P e <br /> Owner's Name ' = e Phone <br /> r. City I' <br /> j Address -� <br /> t <br /> Contracto " License Business Phone <br /> r's Name _ C <br /> P Contractor's Address 5� 75 ! /�� ��f Emergency Ph ne <br /> Lis Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> ,TYPE OF WORK (CHECK)----NEW WELL El DEEPEN El RECONDITION 1-1DESTRUCTION❑ <br /> %WELL CHLORINATION ❑ WELL ABANDONMENT OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR 13 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> - Sewage Disposal Field Cesspool/Seepage Pit Other a <br /> I <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 ❑ DRIVEN 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: ❑ State Work Done P <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> f <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 /> I <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 Paws 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 will call for a Grout Insp ction prior to grouting and a final inspection. I _ . ` - = _ • .�- --� <br /> Signed X r Title: <br /> I Date: — — <br /> (Draw Plot Plan on Reverse Side) f <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - '[�l Date `=� <br /> Application Accepted 13 1 <br /> Additional Comments: <br /> Phase II Grout inspection hese III Final Inspection <br /> v <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE EACH ❑ January 1 &Received By January 31 - T❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE _ $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE ,V� LJ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> ^ OTHER .. <br /> l OTHER C` <br /> 31 <br /> - Received by ate Receipt No. Permi 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 9520 / <br />