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Appili n ll 11; 13 rcRes ed ie milted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: V� tt��JJ c.�[ PPLICATION <br /> . <br /> FOR <br /> L' MAR ftNon sferable, Revocable,Suspendable) <br /> Y' �tjjCr��7 <br /> PUMP&W <br /> ENVIRONMENTAL HEALTH PERMIT <br /> COMPLETE IN TRIPLICATE J�.,`IP UIN LOCAL WATER QUALITY <br /> ( )SAN Q @S Coi�aus <br /> Application is hereby made to the W_IghcTi4I..& foltfpistrictforapermittoconstructand/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862/and the rules a/nd_regulations of the San Joaquin Local Health District. <br /> Exact Site Address 30o' d. 0,91S2ity/Town L- de <br /> Owner's Name JQ Phone <br /> Address �D- y y 3� �h map 4��D/ City <br /> Contractor's Name Purviance Drillers Drilling Corp. License# Business Phone31 <br /> Contractor's AddressEmergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ✓ No C16 <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ ZS1 t <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION IQ PUMP REPAIR© <br /> t <br /> REPLACEMENT❑ <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 \ i <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing l <br /> ❑ DOMESTIC/PUBLIC E] DRIVEN Gauge of Casing `1 <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal rr,� <br /> CATHODIC PROTECTION ❑ ROTARY Type-6f Grout �L <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: 3 <br /> PUMP INSTALLATION: 1/11" Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Dane _ € <br /> PUMP REPAIR: ❑ State Work Done i <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 /> 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 shall not employ any person in such manner as to become subject to workman's compensation laws of California." R i <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." i <br /> I will call for a G ut I spection prior to grouting and a final inspection. <br /> k Signed X 4Z lelaLA�4e <br /> r Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> Y <br /> -� FOR DEPARTMENT USE ONLY <br /> PHASE l I'91� � _►1�_ (�i <br /> Application Accepted By lJ Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection ByDate <br /> i <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 ' <br /> - REMIT <br /> I BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> I <br /> FEE <br />� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Iss�rleDateaile Delivered <br /> ( <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOGKTON,CA 85201 <br /> APPLICANT.—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES .� <br />