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r A at� jgil�eAro#ssA ubmitted Properly Completed. Be Sure To Sign The Application. <br /> FGn OFFICE USE: �". ��::J! APPLICATION <br /> �rFor ransferable, Revocable, Suspendable) 1 <br /> APR 19 EPUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATS)AN- JOA U(N LCICA3 WATER QUALITY <br /> Appl ication is hereby made to UMEft"uiD�CM171HOIjth District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862pand the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address SODA /�� �o �c� U ee _ City/Town pr .Ajdeo <br /> Owner's Name k s Phone <br /> Address City GcsA <br /> Contractor's Name Purviance Drillers Drilling Corp. License#313 2. Business Phone <br /> Contractor's Address V_ -_. Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_k____ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION DESTRUCTION❑ r l <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ -OTHER ❑ PUMP INSTALLATION PUMP REPAIR 13 <br /> REPLACEMENT❑ - <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property.Line 4 ^ Private Domestic Well Public Domestic Well <br /> I INTENDED USE '! TYPE OF WELL <br /> 1i, <br /> 11 INDUSTRIAL .. � Il�. � CABLE TOOL Dia. of Well Excavation /dfjQ�i <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 3 <br />} ® IRRIGATION ❑ GRAVEL PACK Depth'of Grout Seal <br /> ❑ CATHODIC PROTECTION I ❑ ROTARY Type oQGrout <br /> ❑ DISPOSAL �I ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL II <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: li Contractor Purviance Drillers Drilling Corp. <br /> Type of Pump H_P. 3 D <br /> PUMP REPLACEMENT: II ❑ State Work Done <br /> PUMP REPAIR: _ a ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter .Approximate Depth SQ. <br /> Describe-Material-and-Procedure,-- ----- <br /> I <br /> F <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 thework forwhich 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." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for Gr t Inspection prior to grouting and a final inspection. <br /> Signed X r !� Ttlie: Pres+ o.;_t Date: <br /> 1 (Draw Plot Plan on Reverse Side) <br />: <br /> I I! <br /> FOR DEPARTMENT <br /> USE ONLY <br /> PHASE I .� <br /> i Application Accepted B - Date Lk—d - <br /> Additional Comments: <br /> Phase II Grout Inspection ha III F' ial Inspection <br /> Inspection By Date Inspection By L/ Date <br /> I Fee Is Due: ❑ ANNUALLY u ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ JUIy 1 &Received By July 31 <br /> REMIT <br /> BASE ; EXPLANATION BILLING REMITTANCE $ <br /> t DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> 1 PRORATION <br /> PLUS it <br /> PENALTY <br /> 17 OTHER I� <br /> OTHER 7 <br /> it <br /> I <br /> Received by - Date n .Receipt No Permit.No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES' 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 .i <br />