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0U[)R1Rlea rrvpMrry r..Vmyrcicar. ac.�uryFOR OFFICE USEr �� �11982APPLICATION <br /> DE <br /> (F on-Transferable, Revocable, Suspend �unnP�WELL /able) -2-1543 <br /> C ' <br /> e ENVIRONMENTAL HEALTH PERMIT /0S --- 0sa -d f <br /> (COMPLETE IN TRIPLI ` 10l,QUIN LOCAL -� WATER QUALITY rj,1 X74 6r CcAP55�ee c t 4 <br /> Application is hereby made6 hili—AdJoQ[1T_I jQ ealthDistrictforapermittoconstructand/orInstalltheworkhereindescribed:Thisapplicationis <br /> made in compliance with San Joaquin County Ordinance No. 1862 anq the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address r '/w F ASO City/Town L/M-4,0a <br /> Owner's Name/.� +^f"V * / (� S Phone <br /> Address �lntssJ M/7�a e_ City _ i4cfeq I'urviance Drillers Drilling Corp. l [ILs1C(e� I <br /> Contractor's Name License# Business Phone vu/ <br /> Contractor's Address -L MZ�m Emergency Phone <br /> ,Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No ' <br /> TYPE OF WORK (CHECK): NEW WELL ElDEEPEN ❑ RECONDITION ElDESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR {� <br /> REPLACEMENT❑ �1' <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy �l/1 <br /> Sewage Disposal Field Cesspool/Seepage Pit Other I <br /> Property Line Private Domestic Well Public Domestic Well <br /> r IN)I'ENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL h ❑ CABLE TOOL Dia. of Weil Excavation <br /> ❑ DOMESTIC/PRIVATE ;i ❑ DRILLED Dia. of Well Casing �� I <br /> ❑ DOMESTIC/PUBLICI C3DRIVEN Gauge of Casing <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal A <br /> ❑ CATHODIC PROTECTION I ❑ ROTARY Type of Grout <br /> O' <br /> ❑ DISPOSAL � � � 13 OTHER Other Information '1 <br /> ❑ GEOPHYSICAL !< Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Purviance Drillers Drilling Cor . <br /> it Type of Pump H.P. ( 1 <br /> PUMP REPLACEMENT: _ 11State Work Done - -- - <br /> PUMP REPAIR: t-/ ❑ State Work Done R. <br /> DESTRUCTION OF WELL: 1, Well Diameter Approximate Depth 4 <br /> Describe Material and Procedure <br /> II <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 toliowing:"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 wpF man'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 for which this A <br /> permit is issued, I shal employ persons subject to workman's compensation laws of-California." ^r <br /> 1 F � <br /> I will call for aout I pection prior 10 grouting and a sinal inspection. <br /> Signed X 11 Title: -.- _ rZ Date: <br /> (Draw Plot Plan on Reverse Side) <br /> ii <br /> FOR DEPARTMENT USE ONLY I <br /> PHASE I 111-Le, <br /> Date <br /> Application Accepted By <br /> Additional Comments: 1" <br /> Phase Il Grout Inspection P e I ction c� <br /> Inspection By -`I 6. Date Inspection By ate <br /> Fee Is Due: ❑ ANNUALLY ,� ❑ PER UNIT _ ❑ PER SITE ❑ EACH ❑ JanuaryReceived By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE'? EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED 1 <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> 1 <br /> LESS <br /> PRORATION .. <br /> PLUS- <br /> PENALTY P <br /> OTHER <br /> OTHER �I <br /> f I <br /> f Received by Date Receipt No. Permit No, Iss ance Date Mailed Delivered <br /> FI APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERACES 1601 E.HAZELTON AVE.,P.O-Box 2009 STOCKTON,CA 95201 - <br />