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Applications Will Be Processed When Submitted Properly Complel e w1rTaig A li 'OFQFFICE USE: APPLICATION i (For Non-Transferable, Revocable,Sus able) ! l ENVIRONMENTAL HEALTH PERMITMAR G 1980 &WELL (COMPLETE IN TRIPLICATE) U'#t� "ft1• Ges7t, `A WATER QUALITY pit p;� �y��+��1�- Application is hereby made to the San Joaquin Local Health District for a permit to construct and,6fLN'ta4Tf'I "' WerLph�'tr#E?stYibed.This application is made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations 1]MTR Health District. Exact Site Address 2/10 mils East Cox Rd; interseetian City/Town Linden Owner's Name Joy AtkixVi Cox and Baker Rd.Phone $87-3667 Address P. 0. Pox:,-671 City Linden Contractor's Name Purviance Drillers Dri11ii&-Q"]a. 377923Business Phone 931-4468 Contractor's Address P. G. BOX 64 Linden Emergency Phone �• Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes XX No (y TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITIONZI DESTRUCTION❑ J) WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR r REPLACEMENT❑ 3 w DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE 13 TYPE OF WELL iott ❑ INDUSTRIAL , CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE j� ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC h ❑ DRIVEN Gauge of Casing .IRRIGATION GRAVEL PACK Depth of Grout Seal S ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ;i ❑ OTHER Other Information 'k ❑ GEOPHYSICAL °' " Surface Seal Installed By: PUMP INSTALLATION: ' ` I! Contractor Sallie II •Type of Pump H.P. _ n PUMP REPLACEMENT:- JO-State Work-DoneTC'place 15HP turbine with 15HP-submer.siable PUMP REPAIR: I ❑ State Work Done DESTRUCTION OF WELL: I� Well diameter 1� Approximate Depth vim' 11 -4 Describe Material and Procedure 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County t. ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. t Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall,employ persons subject to workman's compensation laws of California." I will call for a Gro spection prior to grouting and a final inspection. 1 Signed X Title: President Date: 3/'+I$4 ii _ (Draw Plot Plan on Reverse Side) 1 IL =- I - F DEPA TMENT USE ONLY 13 i PHASE I Application Accepted By— Dat Additional Comments: A 0 4cj�p/� Phase Ii Grout Inspection Fdwse III Final Inspection ` Inspection By 'Date n�spection By Dat f t Fee IS Due: ❑ ANNUALLY PER UNhT ❑ PER SITE 11 EACH ❑ January 1 &Received By January 31 El July 1 8 Received By July 31 ` BILLING REMITTANCE $ REMIT BASE `. EXPLANATION, , .,.-;, ;�,: - ' bA7E DATE REMITTED AMOUNT DUE CHECKED FEE �— LESS " s PRORATION PLUS N PENALTY .. i OTHER II 9 I OTHER i Received by Date Receipt No. Permit.Nu. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95241 A