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Pi tli s I Ivoc&eIm <br /> n Submitted Properly Completed. Be Sure To Sign The Application. <br /> �oR`OF�9CE USE f APPLICATION -` ,lQ�`; . <br /> App 29 <br /> 1981 (For Non-Transferable, Revocable,-Suspendable) <br /> APR s7 1.70 PUMP&WELL —�O <br /> r ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRiPLIC&W JOPQUIN LOCAL WATER QUALITY <br /> Application is hereby made tb•{"THa4NiW 1iG4T.althDistrictforapermittoconstructyand/or install the work herein described.c Ibed.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1662 and the rules and regulations of the San Joaquin Local Health District, <br /> Exact Site Address 2 C City/Town <br /> fOwner's Name T19_e- 5-c <br /> _ _ Q Phone <br /> Address <br /> r— --� City <br /> f Contractor's Name Purviance Drillers Drilling Corp. License# 3 <br /> �� Business Phone <br /> Contractor's Address.__,.C? Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? 1 <br /> Yes ✓ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER`❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ W <br /> REPLACEMENT 1 <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> —Sewage Disposal Field _=Cesspool/Seepage Pit - Other <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 [:P4 -- <br /> . DRIVEN <br /> Gauge of Casing <br /> 19 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL I <br /> Surface Seat installed By: <br /> PUMP INSTALLATION: Contractor Purviance Drillers Drilling Corp. <br /> Type of Pump Y H.P, .30 <br /> PUMP REPLACEMENT: ✓ ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: { <br /> Well Diameter Approximate Depth <br /> Describe Material and Procedure. _ <br /> ordinances, state laws, and rules and regulations of the San Joaquin Loc1 hereby certify-that'I have prepared this application and that the work uvill be done in accordance with San Joaquin County <br /> aalHealth 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 /> I1 call for q­Gr t sp 'on prior to grouting and a final Inspection. <br /> Signed X --Title:.TtNe:—��IwG-2x�Y`��rl a�e_n�- �- Date: <br /> (Draw lot Plan'on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE IIS <br /> Application Accepted By O Date k4_1 p <br /> i Additional Comments: <br /> Phase 11 Grout Inspection r' aseJI I Inspection <br /> In By Date Inspection By ate <br /> Fee IS Due: © ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH 0 Januar 1 &Received B Januar <br /> Y Y Y 31 ❑.July 1 &Received By Juiy 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS } <br /> PRORATION ` <br /> PLUS <br /> PENALTY <br /> OTHER <br /> s <br /> OTHER <br /> Received 6y Date Receipt No, J Permit No. I sua a 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 />