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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. ) <br /> FOF,-_01FFiCe SE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ttt 4", <br /> ENVIRONMENTAL HEALTH PERMIT / <br /> (COMPLETE IN TRIPLICATE)` WATER QUALITY � I <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work hereifi da ribed.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San J$aquin Local Health District. <br /> Exact Site Address O J amity/Town s�C�.r/9C-AC_-4vcj <br /> Owner's Name �!� < I% Phone <br /> Address City_ ,.! <br /> Contractor's Name Purviance Drillers DrillingCorp. License#32,3 Business Phone y`3J— BSc 4,PContractor's Address _ f3.Y Ip f,4 -L.fh q(ey Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes P-__ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <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 <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 /> JR IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL I <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Purviance Drillers Drilling Corp <br /> Type of Pump TitY'k," H.P. 30 <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 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 /> Homeowner 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 tii ' or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> _ permit is issued, I s II employ persons subject to workman's compensation laws of California." <br /> �A.. I will' a ou spection prior to grouting and a final insp tion. ) <br /> Signed")( �iC c Title: j '�cE LFsG �— _� <br /> Date: <br /> (Draw Plot Plan on Rever a Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By U Date- �7�� /r <br /> Additional Comments: <br /> Phase If Grout Inspec ion a 11 Final Inspection <br /> Inspection By ✓ Date Inspection By D to <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Aeceided By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE "EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuande Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.;P.O.Box 2009 STOCKTON,CA 95201 <br />