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Applications BArocessed When Submi t roperly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: it� 91 - ��Q A CATION e�'7 , Cplslplr?/ tory dq l e_ <br /> AP NFIr�oilAInsferable, Revocable, Suspendable) , AIZ F Y/ <br /> t PUMP&WELL y <br /> SANS rF1�Ill�f _lEF�TAL HEALTH PERMIT J <br /> (COMPLETE IN TRIPLICATE) HEALT��H� DISTRJ�WATER QUALITY I <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 Joagpin Local Health District. <br /> � <br /> Exact Site Address eR s/U. �S" v — e- City/Town <br /> ,C,inde/'f <br /> Owner's NamDI'+'t p Phone 9,Y'j— 32 OR ' <br /> Address _2V_70_-9 -e_ City -� <br /> Contractor's Name Purviarce Drillers Drilling Corp. License#371'12S Business Phone 931-_44 4, ,Z <br /> Contractor's Address — 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❑ 4 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ® PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other I <br /> Property Line Private Domestic Well Public Domestic Well I <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 /> la 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: ..f <br /> PUMP INSTALLATION: c/ Contractor Purviance Drill o ' <br /> Type of Pump t H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done �- <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth y <br /> Describe Material and Procedure s <br /> .I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County I <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 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." y <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this JI <br /> permit is issued, I shall employ persons subject to workman's compensation laws_ of California." <br /> I will call fora r nspection prior to grouting and a final inspection. <br /> Signed X 1 Title: pri—, Sfrci�vt ___ Date: 41 — s_?f <br /> (Draw Plot Plan on Reverse Side) <br /> V I <br /> FOR DEPARTMENT USE ONLY F <br /> PHA <br /> E I <br /> Application Accepted ByL ' Date <br /> Additional Comments: <br /> Ph se Il Grout Inspection }Phase III Final Inspection <br /> i <br /> Inspection By Date a 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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT OUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> r <br /> OTHER <br /> OTHER <br /> I <br /> ids 9 i <br /> Received by Date Receipt No. Permit No Issuarke Date MailE(d Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />