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- ApplTA <br /> inYlfillaBe Processed Whe jI matted Properly Completed. Be Sure To Sign The Application. <br /> �FOR,04FICE USE: �A :JP8� APPLICATION �s�. �v�p/�r� �„ _J-, <br /> i 1YI�Y or Non-Transferable, Revocable,Suspendable} <br /> 1 PUMP&WEi.t (� I <br /> I r`;f 1-,NEN.VV1_9bNMENTAL HEALTH PERMIT <br /> I SAN _` <br /> (COMPLETE IN TRIPLICATE) -M IDIST RIC` WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora 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 the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address �.�� _ City/Town flf?de,n <br /> Owner's Name a Y I'a 3 19 4 04 12 Phone <br /> Address .Ski City ,! <br /> Contractor's Name Purviance Drillers Drilling Corp. License#37?f23 Business Phone 172 <br /> Contractor's Address - Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHO? Yes 4-ff�__ No IA <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION C1 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT O <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 /> 0 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN . Gauge of Casing l <br /> 5a IRRIGATION ❑ GRAVEL PACK Depth'of Grout Seal <br /> 'k` ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Puryiance Drillers Drilling-torp, <br /> Type of Pump H.P. /62 <br /> PUMP REPLACEMENT: ✓ ❑ State Work Done i <br /> PUMP REPAIR: ❑ State Work Done T <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure 4� <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:1 certify that in the performance of the work for which this permit y <br /> ' is issued, I shall not employ any person in such manner as to become subject to.workman's.compensation_laws of California." <br /> - <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the pertormance of.the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 1 call for Gro 1 I eclion prior to grouting and'a finale inspection. — <br /> Signed X L �v Title: I/ s_q -...�r�5l e`I"1` _ Date: s <br /> (Draw Plot Plan on Reverse Side) J <br /> FOR DEPARTMENT USE ONLY <br /> PHASE IarN t <br /> Application Accepted By~ Date <br /> Additional-Comments: ` <br /> i Phase II Grout Inspection Pha a It nal Inspection <br /> Inspection By Date Inspection By Date <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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE AMOUNT DUE CHECKED <br /> REWTTED <br /> AMOUNT <br /> r FEE <br /> LESS <br /> PRORATION <br /> t PLUS <br /> -PENALTY <br /> OTHER <br /> it <br /> ! OTHER <br /> Received by Date Receipt No. Permit No. Is ante Date Mailed -Delivered <br /> I APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTHPERMIT/SERVICES- 1601 E.HAZELTON AVE.;P.O.Box 20'09- STOCKTON,CA 95201 <br />