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Applications Will Be Processed When Submitted Properly Complete Segnaliv4pat�rt�� <br /> FOR OFFICE USE- Iil. ' = APPLICATION E�" L� <br /> t I (For Non-Transferable, Revocable, 5usp le) <br /> - DEC <br /> 1980 PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT --- <br /> (COMPLETE IN TRIPLICATE) ! �,-WATER QUALITY SA I JC -,I It I LOCAL <br /> Application is hereby made totheSanJoaquinLocalHealthDistrictforapermittoconstructand/orinht !MkOY�7f1} ibed.Thisapplicationis <br /> made in compliance with San Joaqulin County Ordinancesn No. 1862 and the rules and regulations oftheJoaquin Local Health District. <br /> Exact Site Address 1 I kL.P� City/Town -/I7de� <br /> seG n.,.cp . <br /> Owner's Name. ��� F Z�' Phone II � II <br /> Address 20/�a yo�p` City 4-a-Y j r n j <br /> Contractor's Name Purviance Drillers Drilling Corp. License# 779 Business Phone 93l- 41 V lI <br /> Contractor's Address - Emergency Phone ry <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No 4 # <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN 11 RECONDITION 13DESTRUCTI0N 11 Q i <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ElOTHER ❑ '. PUMP INSTALLATION ❑ PUMP REPAIR C1 — <br /> REPLACEMENT H <br /> DISTANCE TO !NEAREST: Septic Tank Sewer Lines0Pit Privy i <br /> •�°` <br /> Sew ge 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 ' ❑ DRIVEN 1 Gauge of Casing <br /> IRRIGATION ❑ GRAVEL PACK _,Depth.of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout I <br /> ❑ DISPOSAL ❑ OTHER " �- OthdTlriformation <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Purviance Drillers Drilling Corp, <br /> Type of Pump: -1 - - -� H.P 7s r <br /> r <br /> PUMP REPLACEMENT: State Work Done ReOrace -Bo��s 'aI- rFX7er�d .P n <br /> r <br /> PUMP REPAIR: ❑ state Work Done F <br /> DESTRUCTION OF WELL: i; Well Diameter Approximate Depth 5 <br /> Describe Material and Procedure s <br /> I hereby certify that I have prepared this application and that the work will tie done in accordance with San Joaquin County F' <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Healthbistrict. <br /> Homeowner or licensedogent'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." E <br /> I will call for a Grout Inspection prior to grouting and a final inspection."., (j <br /> E. f <br /> Signed X �f, Title: f Date: <br /> yG _ (Draw Plot Plan on Reverse ,,, _�,� Vf <br /> r1F ` M <br /> FOR DEPARTMENT USE ONLY ' <br /> PHASE I �° Q e) <br /> Application Accepted By-- <br /> Additional Comments: <br /> Phase��ll Grout Inspection a Ili Final Inspection- ? <br /> Inspection By,Ma� Date Inspebtion By Date <br /> 1 - l <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 .r <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE ipl�`III EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> IIII AMOUNT <br /> FEE Ag.. I! i <br /> LESS <br /> PRORATION :I�: Ad 7 <br /> PLUS <br /> PENALTY <br /> OTHER III <br /> OTHER _,II <br /> Ill I i�-U . <br /> Received by Date 'I�i Receipt No, Permit No. suanc Date Mailed Delivered <br /> 4 APPLICANT-RETURN ALL COMES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES -- 1601 E.HAZELTON AVE-.,'P.O.Box'2009 STOCKTON;CA-95201 <br />