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I OOC a n Submitted Properly Completed. Be Sure To Sign The Application. <br /> FPR OFFICE USE: APPLICATION —t^ �, 3© <br /> eh�7`i� . <br /> '0 <br /> MAR 2 3 19. 1 (Fo n-Transferable, Revocable, Suspendable) PUnn>'&WELL <br /> r <br /> E V RONMENTAL HEALTH PERMIT <br /> `C'Cf3 N- x. . <br /> (COMPLETE IN TRIPLI �.kahl-I h:R.t:lam N LOCAL WATER QUALITY'' <br /> 4� q <br /> Application is hereby made IdbaQ�tll)EROTOalth 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. 1662 and the ru es and regulations of the San Joaquin Local Health District. . <br /> R Exact Site Address _��_ �7 �� City/Town re_rr2 e_s, TJ- <br /> Owner's Name �rl4Y/ Phone <br /> e <br /> .AddressO-_� !r/ City �li�,v�ri��:� o� <br /> Contractor's Name Purviance Drillers Drilling Corp. License#377'123 Business Phoneme rv? <br /> Contractor's Address )?II_ ;?2—(nc,C — L.11M ale,? Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD7 Yes - �� No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ _J <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMPINSTALLATIONS 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 /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal + <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout Q k <br /> ❑ DISPOSAL ❑ OTHER Other Information I <br /> ❑ GEOPHYSICAL Surface-Seal Installed By: C <br /> PUMP INSTALLATION: Contractor Purvian–cye�+Drillers }; <br /> Type of Pump 1 LCr - N.P. �s l <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 4 j <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. - JI <br /> Home owner or licensed agents signature certifies the fallowing:"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:"l certify that in the performance of the work forwhich this a t <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." l i <br /> I will call,for a r spection prior to grouting and a final inspection. i <br /> Signed X Title: �e-.T 1 07 Date: <br /> kff ffz�" ___ - <br /> (Draw Plot Plan on Reverse Side) <br /> } <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I i <br /> Application Accepted By ! O Datea - ` <br /> Additional Comments: <br /> Phase II Grout Inspection III Final Inspection <br /> Inspection By Date Inspection By Date L t? <br /> Fee Is Due: 11 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Januar 1 &Received B Januar 31 <br /> Y Y Y ❑ July-T&Received By July 31 <br /> BILLING REM#TTANCE $ REMIT <br /> BASE EXPLANATION PATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS I <br /> PENALTY <br /> OTHER <br /> OTHER <br /> fy �qvrl <br /> Received by Date Receipt No Permit No.: Issua ce Date Mailed Delivered <br /> R <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 j <br />