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Applications Will Be Processed When Submitted Properly Completed. BeSureTo sign inewppucae+vr <br /> FOR Orf ICE USE: APPLICATION f <br /> (for Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT � r <br /> (COMPLETE IN TRIPLICATE) <br /> WATER QUALITY ��4_/-7ar� '44elde <br /> k <br /> Application is hereby made to the San Joaquin Local Health Oistrictfora permit to construct and/or install the work herein described.This application Is} <br /> I y Ordinance No. 1862 and the rules a d <br /> _made in com liance with SaCity/Town <br /> EJoaquin Coun regulations of the San Joaquin Local Health District. <br /> p �ji./ r. <br /> xact Site Address �Q`� ``'{" � 4 <br /> Yr i?_S let Phone <br /> Owner's Name ; � City Srt�c r- r"d' <br /> Address G L.r /:r �.�/- u</6 47 <br /> Contractor's Name Puryiance Drillers Drilling Co!p. License# 3 �3 Business Phone <br /> Contractor's Address <br /> fp y! Emergency Phone - <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITIONIN DESTRUCTION❑ <br /> WELL CHLORINATION 11 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 IN CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE 11 DRILLED Dia. of Well Casing ���'�� <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing f <br /> 3 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal _ <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout N <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: V) <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> '3e <br /> PUMP REPLACEMENT: ❑ State Work Done Ia <br /> PUMP REPAIR: �] State Work Done <br /> DESTRUCTION OF WELL: IWell Diameter <br /> 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 hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work€orwhich this <br /> permit is issued, I shall employ persons subject to workmarirs compensation laws of California." <br /> I will call for Grou nspection prior to grouting and a final int �D <br /> I <br /> Title: specion. �� Date: <br /> Signed X <br /> (Draw Plot Plan on Reverse Side) -----��--� -• <br /> FOR DEPARTMENT USE ONLY <br /> .E <br /> PHASE I _ Date AV <br /> Application Accepted By <br /> I Additional Comments: <br /> Phas rout Inspection Phase I11 Final Inspection <br /> Inspection By <br /> 1 Date Inspection By Date <br /> Bys <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ElPER SITE ElEACH E3 January 1 &Received By January 51 C] July 1 &ReceivedREMITu y 31 <br /> B4LLING REWTTANCE $ AMOUNT DUE CHECKED <br /> f BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> a <br /> FEE <br /> LESS <br /> PRORATION <br /> } PWS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> M �/, l � <br /> ate p - _Pern`�NO. I uan e ate Mailed Delivered <br /> Received by Receipt No. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENT�4L HEALTH PERMITISERVICES 1601 E.HAZELTON AYE.,P.O.bow 2609 STOCKTON,CA 95201 <br />