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dplloitioft Nihil EWPr6Ceisbd}Wken Submitted Properly Compk f-i 1 B ' u o The Application. �� <br /> ]FOR OFFICE USE: r!iFor II APPLICATM e-57-. d�rc- 3�� „.- �llJ13 198 c Non-Transierable, ` clpuspendablENVIRONMENTAL LTH" FRRA r r N\, PUMP&WI=LL <br /> SAN JL�.�,QU[ Ni C y '..:1L S <br /> I ((COMPLETE IN TRIPLICAI�EALTH Din l- l WATER Q Y c,. OCA �� ©��dZ <br /> pplicationisherebymadetotheSanJoaquinLoca ealthDistrictforapermittoconstruca eibis'�lt#heworkhereindescribed.Thisapplicationis <br /> 1 made in compliance with San Jquin County Ordinance No. 1862 and the rules and�iaitps)of the San Jo quip Local Health District. <br /> s Exact Site Addressl- <br /> I �} City/Town <br /> Owner's Nam/e. I�GLI' f v Phone C�1 <br /> Address �01444. , �I�P+'1 1i e,Qt ._�s_. T <br /> r 0 - City r" <br /> i Contractor's Name Purviance Drillers Drilling Corp. License# 3 <br /> �` Business Phone <br /> Contractor's Address s Emergency Phone <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes L___ No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑,." RECONDITION❑" DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 91 <br /> REPLACEMENT PUMP REPAIR❑ <br /> ❑ - <br /> w <br /> ! DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field s Cesspool/Seepage Pit Other <br /> Property Line .Private Domestic Well Public Domestic Well C� <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED L Dia. of Well Casing <br /> I ❑ DOMESTIC/PUBLIC11 DIVEN R <br /> I - � � Gauge of Casing ' <br /> I IRRIGATION ' a '- " '` .� ❑ GRAVEL PACK' - - _ " <br /> - .- Depth of Grout Seal <br /> f ❑ 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 U�� H P <br /> PUMP REPLACEMENT: ❑ State Work Done <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.pFepared 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 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." i <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 shall employ persons subject to workman's compensation laws of California." <br /> I will call fora r In ection prior to grouting and a linal inspection: <br /> r <br /> - 7 <br /> Signed X Title: Date:_ <br /> (Draw Plot Plan on-Reverse Side) - - <br /> PHASE f <br /> FOR DEPARTMENT USE ONLY <br /> ��. `- - ,� <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase If Grout Inspection s. '_" - iiise 11 Final Inspection <br /> Inspection ByJ .Date •- �''A :Inspection By bate ' 1 <br /> Fee Is Due: ❑ ANNUALLY ! ��❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 © July 1 &Received By Juiy 31 <br /> BASE -,rEXPLANATION BILLING REMITTANCE $ REMIT <br /> .I <br /> DATE DATE REMITTED .AMOUNT DUE CHECKED <br /> ? AMOUNT <br /> FEE # <br /> a <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY R <br /> "� Is <br /> OTHER <br /> OTHER <br /> Received by Date Recei t No- -�-� -•--p Pe^nance to Mailed DeIvered <br /> ' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES .1601 E.HATELTON AVE.,P.O.Box 2009 STOCKT! _� <br />