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) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <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 Sap Joaquin,,C�fount Or finance No. 1862 and the rules and regulations of the San aqui �j� oval Health Di riot. <br /> Exact Site Addres�sT 0 W/11 cir AOu z City/Town 6C 'L0" Q <br /> Owner's Name T04+4ia� s4- Phone <br /> Address <br /> City <br /> Contractor's Name f+l�►�G — License#�? 1J Business Phone " 2- <br /> Contractor's <br /> Contractor's Address L Emergency Phone t <br /> Is Certificate of Workman's CompensationIn rance on File With SJLHD? Yes—J — No _ <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION El DESTRUCTION❑ `� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ r <br /> DISTANCE TO NEAREST: Septic Tank 15in Sewer Lines j4 Pit Priv <br /> Sewage Disposal Field Cesspool/Seepage Pit ©a Other <br /> - <br /> Property Line{I 4 Private Domestic Well,__; Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> to I <br /> q, INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> LDOMESTIC/PRIVATE' ❑ DRILLED Dia. of Well Casing <br /> �D DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal 1 <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout L�EstiI friC <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: �-- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 10 <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 nature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I s II a oy pers subject to workman's compensation laws of California." <br /> I c r t In Otto <br /> Ing and a final inspection. <br /> Signed X Title: A,,-t_ – <br /> ti – Date: J ` Q <br /> (Draw Plot Plan on Reversedde) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By <br /> Additional Comments- _ <br /> Phis I r u I sppe tion .�,_� Phase III Final Inspection <br /> inspection B t ^Inspection By Date <br /> Fee IS Due: ❑ ANNUALLY PER UNIT ❑ PER SITE ❑ EA ❑ January 1 & e e e By January 31 ❑ July 1 R Received By July 31 IJ <br /> BILLING RE NCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE d. 4 <br /> LESS 1� <br /> PRORATION <br /> )' t <br /> PLUS <br /> PENALTY <br /> OTHER I <br /> OTHER <br /> C) <br /> Received by Date Receipt No. Permit No lssuanc4 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 />