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Applications Will Be Processed When Submitted Properly Completed. Be Sure To r"hppgcqlon. <br /> FOR OFFICE USE: APPLICATION Tvd <br /> (For Non-Transferable, Revocable, Suspend PUM ELL <br /> ENVIRONMENTAL HEALTH PER Qr- I <br /> CT 16 1981 <br /> r '(COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health District fora permit to construct and/or in tJ# e ork,�h�rgi deser�blgThis application is <br /> made in compliance wiith��4 oaqui County Ordinance No. 1852 and the rules and regulations of tl�e�S�&n 1910l.Nj�•oje i�kierlt District. <br /> Exact Site Address e-'r6p3vf 1> City/Town <br /> Owner's Name W , Phone _ 6-S -ur'o�tp <br /> Il Address 115 G9mo /1_C City • <br /> Contractor's Name Arnpinnre Drillerg License#32792? Business Phone '9 44 G <br /> Contractor's Address - Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes v No <br /> TYPE OF WORK (CHECK}: NEW WELL <br /> 13 DEEPEN 1:1 RECONDITION 13DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL A13ANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ® PUMP REPAIR❑ I <br /> REPLACEMENT❑ DD <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy p l <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> I Property Line Private Domestic Well Public Domestic Well i <br /> INTENDED-USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Weil Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing `! <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal \n <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout `U <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: r/' Contractor Purviance Drillers Drilling Corp. <br /> Type of Pump H.P. <br /> 1,00 <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"County <br /> ordinances, state laws,-and rules a_nd_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 /> is issued, I shail-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 /> E permit is issued, I shall employ persois subject to workman's compensation laws of California.' <br /> I will cal or a Grout Inspection prior'to grouting and a final inspection. / <br /> Signed X yJ�7 7 L� �,S ' n Date: <br /> / -- -- (Draw-Plot Plan on Reverse Side) - -- - <br /> FOR DEPARTMENT USE ONLY <br /> PHASE l �� � <br /> Date <br /> Application Accepted By <br /> Additional Comments: - <br /> Phase 11 Grout Inspection Phase III Final Inspection <br /> Inspection By <br /> Date Inspection By 7!0 �^ "- Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH*e❑ January 1 &Received 8y January 31 ❑ July 1 &Received By July 31 <br /> F _ REMIT <br /> F BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> r - <br /> ' FEE <br /> f <br /> € LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> & <br /> Re eived y to - Receipt No. Permit No. Issuance Date Mailed Delivered <br /> r <br /> .APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Bo=2009, STOCKTON,CA 95201 <br />