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-1slgn Inew <br /> Ap licaat bl&i-tBeProcessed�n Submitted Properly Completed. Be sure ppl� Icw ' <br /> FOR OFFICE USE: o�f � APPLICATION — �+-• � <br /> (For NckrtTransferable, Revocable,Suspendable) PUMP&WELL <br /> rs fffIONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) �,�?� <br /> WATER QUALITY �1� <br /> Application is hereby made to the San-J � in Local Health 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 o. 1862 and the les'an�d�regpulat <br /> 0 1 r ions of the San Joaquin Local Health District. <br /> Exact Site Address <br /> c� QOM f ��-d_ City/Town 4 rode <br /> Owner's Name Phone ' <br /> Address 76* <br /> City <br /> Contractor's Name <br /> Purviance Dr'i lers Drilling Corp. License# Business Phone 93/^ t ^) <br /> Contractor's Address L 9S234Emergency Phone _ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes z No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ —Q <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRM <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer ines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well i <br /> INTENDED USE a TYPE OF WELL• <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ^- <br /> ` , ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC V ❑ DRIVEN Gauge of Casing <br /> 10 IRRIGATIONSF• A❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION* ❑ ROTARY Type of Grout I <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal installed By: <br /> PUMP INSTALLATION: Contractor Purviance Drillers Drilling Corp. <br /> Type of Pump H P <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: <br /> ® State Work Done <br /> -- <br /> DESTRUCTION OF WELL: Well Diameter <br /> pp�roximate Depth <br /> Describe Material and Procedure_ <br /> I hereby certify that I have preps ed this lic <br /> appation 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." <br /> Contractor's hiring or sub-contracting signature ceriifies•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." <br /> I will call for G o Inspection prior to grouting and f al inspection. TM <br /> Signed X <br /> Title: Date: <br /> — <br /> (Draw Plot Plan on Reverse Side) — � <br /> FOR DEPARTMENT USE ONLY f <br /> PHASE I Date1a C3 <br /> Application Accepted By <br /> Additional Comments: e_4% y _ <br /> Phase-II rout fnspeciiori µ P F' ectian <br /> ' Inspection 8y Date �— <br /> Inspection By. Date. — — <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE -❑ EACH ❑ January eceived By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE K. DATE REMITTED —AMOUNT <br /> FEE <br /> �. LESS <br /> PRORATION <br /> PLUS <br /> f PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No, Issu nce[Ate Mailed Delivered <br /> ' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009- STOCKTON,CA 95241 <br />