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` a{ n�INIl� e\pronss dWhen Submitted Properly completea. Isesure Ia sign IneMPF11L0%1WF1. <br /> FOR FFICE US Ll APPLICATION � �a7,vL - J-14 P7 e- 30 +� <br /> MAR 28 1981 ( or Non-Transferable, Revocable,Suspendable) <br /> � PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLI M).I0rr`1��;,I�j i ry Al WATER QUALITY <br /> Application is hereby mad444-FTaMJoa tLSrrL�alHealthDistrictforapermittoconstructand/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> rf, . <br /> Exact Site Address ,,7!0�� w v 26 ` i O t�� Clty/Town �+�e►�r <br /> I Ar <br /> Owner's Na a Phone <br /> Address 0— &X City e <br /> Contractor's Name Purylance. License#3071a_ Business Phone <br /> Contractor's Address — Ll Emergency Phone <br /> is 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 0 PUMP REPAIR❑ <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 <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <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 <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: ✓ Contractor PurViance Drillers Drilling Corp. <br /> Type of Pump Ybje.2 H.P. <br /> PUMP REPLACEMENT: ❑ State Work Dane _ <br /> PUMP REPAIR: ❑ State Work Done <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. o� <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 certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I sha I employ persons subject to workman's compensation laws of California." <br /> I wil call fora r u nspection prior to grouting and a final inspection. _ <br /> Signed X Title: Date: — <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection ase I4lnspectioIn / <br /> Inspection By Date Inspection By e r <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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEES <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY ' <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed DOivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Sox 2009 STOCKTON,CA 95201 <br />