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Applications Will Be ProcessedWhenSubmitted PropertyL:ompi i sure Ivo+y++ Ilionrrau.v <br /> EFOR]OFFICEfUSE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WI"1,C <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) z2G o* TE ALITY r0_5_ 0(PC•-I( <br /> Sj He <br /> Application isf,erebymadetothe�anJoaquinLocalalthDistrictforapermittoconstruct and/or iinstal lthe 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 {r u .fit " �f, o,+ ='`.! '" C r ' f - 3f r City/Town Jrr <br /> �` 'i,) C,, <br /> Owner's Name !"U -n Phone <br /> Address 2(14, l !, r1 City <br /> urviance n er rl n1g Orp. License#� �z� Business Phone <br /> Contractor's Name • I <br /> Contractor's Address JLLJ`- Emergency Phone a <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes V No CJ <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION 13 WELL ABANDONMENT El OTHER El :PUMP INSTALLATION 11 PUMP REPAIR❑ <br /> REPLACEMENT IN <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 nl <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information d <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Purviance Drillers Drilling Corp, <br /> Type of Pump ��H}}.P. <br /> PUMP REPLACEMENT: ® State Work Df• <br /> one ' ±* 'jos `# EX7en."� /'41 Ih►? <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." a <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 a Grout Inspection prior to grouting and a final inspection. ' 1 <br /> 1 <br /> Signed X T �:}r/ Title: Y e— d <br /> S l C-✓t1' Date: a� � <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT <br /> ,USE ONLY <br /> PHASE 1 .a1 ��°. <br /> Application Accepted By — Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase Ill Final Inspection <br /> Inspection Bylw_. Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 $Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE A� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> A s ;•t. <br /> OTHER ` 4' <br /> OTHER <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.,A.O.Box 2009 STOCKTON,CA 95201 <br />