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Ap captioJnia Will Bete odesse Vl �ubmitted Properly Completed. S� Su Sign application. <br /> yI n �', <br /> FOR OFFICE USE: % APPLICATION t�1`�" <br /> Non-Transferable, Revocable,S ble) 7 <br /> P&WELL <br /> 046NMENTAL HEALTH <br /> ATER QUALITY <br /> (COMPLETE IN TRIPLICATE)" r <br /> Application is hereby mad aquff ddlHe hDistrict for apermit toconstruct and/or in l'I 11ek 6rkhereindescribed.Thisapplicationis j <br /> made in compliance with San L4 Joa n Ordinance No 1862 and the r les and regulations of the San Jo a in Local Health District. <br /> Exact Site Address .25�' �; City/Town <br /> Owner's Name /' [ *ke, CC/4""s Phone <br /> Address — o�-Of:j�91^r� 'J� City 3 O <br /> Contractor's Name purylprice Qrijlers Drilling orp. <br /> License#3?79.23 Business Phone <br /> Contractor's Address 64L fI�__hcmy 61hdch ?5� Emergency Phone ► <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No rn <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ V ► <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 J <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL f <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'lnstalled By: <br /> Casing( <br /> INSTALLATIO Contractor <br /> Type of Pump 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 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. 4`1 <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 hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for ut spection prior to grouting and a final inspection. <br /> 0- _ <br /> Signed X r Title: I^[?S( Date: - <br /> f .(Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE ' <br /> Application Accepted By 0.3 Date 's <br /> Additional Comments: <br /> Phase y II Grout Inspection Phase III Final Inspection <br /> Inspection By2M, (�M^^�"` Date Inspection By ate <br /> I <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ y 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE V <br /> LESS <br /> PRORATION <br /> i <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt NO. Permit No. Issuance lbate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2409 STOCKTON,CA 95201 <br />