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1i¢I�caitigrl YYWB4�Pr*eskgdSubmitted Properly Completed. Be Sure To Sign The Application. <br /> FFFiCE USE: rut <br /> APPLICATION � t-t- <br /> „- '` M�A ��8IFor Non-Transferable, Revocable, Suspendable) 30 <br /> fRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLiCA��/, i i t,,10211�iQUIN LOCALWATER UALITT <br /> Application is hereby madetot N1TJ agtrf�l'P cW1e1IthDistrictforapermit toconstruct 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 Joaquin Local Health District. <br /> Exact Site Address 0��� 01WM im 5 94 City/Town <br /> Owner's Name ' r , Phone <br /> Address _ <br /> Contractor's Name �Purvrence Drillers Drilling Corp. _ License# 77%13 Business Phone 1F3/ �— <br /> Contractor's Address 6 - err 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❑ �. <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 i <br /> ;9IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> -4,CATHODIC PROTECTION ❑ ROTARY Type of Grout 1 <br /> ❑ DISPOSAL ❑ OTHER Other Information �1 <br /> ❑ GEOPHYSICAL T _ - r Surface Seal Installed By: <br /> PUMP INSTALLATION:— - Contractor Purviance Drillers Drilling Corp <br /> C <br /> - Type of Pump big,fe H,P. f/ r <br /> PUMP REPLACEMENT: 4. <br /> ' State Work Done `f <br /> PUMP REPAIR: ❑ 'e {� f <br /> 5tate.Work Done <br /> DESTRUCTION'OF WELL'. - 'Well Diameter. -u <br /> - �"`-`"` Approximate Depth -� •- - __ �y;,.. <br /> Describe Material and Procedure " <br /> vi r <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 O 1 <br /> is issued, I shall not employ any.pe-rson in such manner as to become subject to workman's compensation laws of California." 1 ? <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 for a Gro Ins a ion prio�to-grouting and.a final inspection. <br /> Signed X F Title: - - re--.3 Date: —�/�_117 <br /> (Draw Plot Plan on Reverse Side) ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Q- 1 I <br /> Application Accepted By �`' �'�'.�\ _— Date �` � <br /> Additional Comments. <br /> Phase Il Geout Inspection s�IF, tion <br /> /y r <br /> Inspection By Date Inspection By te 7� <br /> FeeIs 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 PATE DATE REMITTEp AMOUNT OUE CHECKED <br /> AMOUNT <br /> FEE s' <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER r` <br /> Received by Date Receipt No, Permit No. 'Issuance 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 />