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1 App td1 0e+rb6es%ed`Whe mitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: I 1 - APPLICATION %eovirt�c� __`�4s?e. <br /> q O3t� <br /> 23 rlNon-Transferable, Revocable, Suspendable) <br /> NMENTAL HEALTH PERMIT � PUMP&WELL � <br /> ``,;z)UI I1N�f''�yRc <br /> (COMPLETE IN TRIPLICATE) <br /> SAN U WATER QUALITY: <br /> {`J U. <br /> DISTRICT <br /> Application is hereby made to the a o quln Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and he rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address DO SCity/Town �1 hod <br /> Owner's Name �_ ��if Ci(ey� Phoneme <br /> Address 142 9!7 r JNr,)v' Z(0 City L%rides, _ <br /> Contractor's Name Put•viance Drillers Drilling Co . Li'cense#�7'���3 Business Phone 93I- �,L 4�lvOV 01'� <br /> Contractor's Address "Z> �n Emergency Phone �- <br /> Js Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_ �� No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION,Q PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other l <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 Q. <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout '" ` '.. <br /> ❑ DISPOSAL ❑ OTHER Other Information i <br /> ❑ GEOPHYSICAL Surface Seal Installed By: Y <br /> PUMP INSTALLATION: ✓ Contractor Purviance Drillers Drilling Corp. <br /> Type of Pump H.P. ' <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: y Well Diameter Approximate Depth t <br /> Describe Material and Procedure -. <br /> I hereby certify that I have prepared this application and that the work be done in accordance with San Joagluin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Loca1_ lealth District. 1 <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this LCalifornia."' <br /> ermit <br /> r-is--issued,-I shall not employ any person-in such manner as-to become subject to workman's compensation4aws <br /> Contractor's hiring or sub-contracting signature certifies the-following:�-I certif*-that in the performance of tft workthispermit is issued, I shall employ persons subject to workman's compensation laws of California." `r <br /> I will call for a r spection prior to grouting and a final inspection. �• '� <br /> Signed X Title: I��ryT Date: <br /> (Draw Plot Plan on Reverse Side) <br /> � s <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 <br /> Application Accepted By � '`-'�""' - au\, —Date �-C <br /> � <br /> Additional Comments: <br /> Phase ll Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By-�;� '.u..- Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By JuEy 31 <br /> BILLING REMITTANCE $ REMIT <br /> • BASE EXPLANATION . .. � AMOUNT DUE `� CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> Ty S <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No, Issuance M ledelive[� red <br /> APPLICANT—RETURN ALL COPIES TO: -ENVIRONMENTAL.HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />