Laserfiche WebLink
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) T <br /> f' { PUMP&WELL <br /> _ ENVIRONMENTAL HF-ALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application i#hereby made to the San Joaq uin Local Health District fora permit to construct and/or install thework herein described. <br /> This application is <br /> made in compliance with San Joaquin County Ordinancg.No. 1862 and t e rules and regulations of the San aquin Local Health District, <br /> Exact Site Address � � i City/Town 1 C <br /> r <br /> Owner's Name ' Phone `r <br /> Ad d ress <br /> City t _ <br /> Contractor's Namec License# �3�.?�/ Business Phone / 1 <br /> Contractor's Address ` Emergency Phone +:' <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? YesNo <br /> TYPE OF WORK(CHECK): NEW WELL - DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 15Sywer Lines `pit privy <br /> Sewage Disposal Field—� _�_��Cesspool/5e pageTPit _ - ' .Other <br /> Property Line 4! Private Domestic Well� Public Domestic Well <br /> INTENDED USE TYPE OF WELL - Ii <br /> ❑ INDUSTRIAL #' ❑ CABLE TOOL J +1 <br /> Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑IpRILLEDs Dia. of Well Casing c� <br /> DOMESTIC/PUBLIC ❑-`DRIVEN """"""'-auge f g, r <br /> Gauge of Casing <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTIONR6TA6Type of Grout > <br /> El DISPOSAL OTHER Other Information r <br /> ❑ GEOPHYSICAL alled By: <br /> PUMP INSTALLATION: � Surface Seal Instr I <br /> Contractor1. <br /> ,.. <br /> Type of Pump <br /> PUMP REPLACEMENT: v4 El Work Done <br /> PUMP REPAIR: -'-L7 state-Work Done ti It } <br /> DESTRUCTION OF WELL `Well Diameter <br /> 111 +� <br /> ,,, :. Approximate Depth <br /> Describe Material and Procedure t <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 /> mss. 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 certifi s the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall empl7kLPdo"o--grouting <br /> ersons Subject to workman's compensation laws of California." <br /> I wil call for Gr Ins ctI %*' "'t <br /> and a final inspection. <br /> Signed X <br /> Title: ^U Date: S <br /> s (Draw Plot Plan on Reverse Si ) <br /> J <br /> FOR DEPARTMENT USE ONLY <br /> PHASE A f <br /> Application Accepted By <br /> Additional Comments: <br /> Phase 11 Grout Inspection Ph se III Final Inspection <br /> Inspection By Dat;�) Inspection By Date "" "i <br /> Fee Is Due: ❑ ANNUALLY PER UNIT [.�t❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 8 Received By July 31 <br /> BASE "'{' EXPLANATION" BILLING REMITTANCE $ REMIT <br /> i DATE DATE REMITTED AMOUNT DUE , CHECKED <br /> AMOUNT ' <br /> FEE 3 I <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> OTHER <br /> OTHER <br /> w. Received by Date z-- Receipt No.- Permit No, .- Issuanc Da Mailetl - .Delivered <br /> — APPLICANT—RETURN ALL COPIES 70: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />