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nppnuaaonswilllieProcessed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) t. ���h'_' WATEgD ,ALITY �D:c'_ p(pU—/( <br /> Application is hereby made to the San Joaquin Local ealth D istrict for a permrtto construct 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 IJP„ -�-', . - /)l, �,t ;,I ,,7 ,/, , _ 1, .Cit /Town <br /> Owner's Name - 1 F14 I(,001-t '(') <br /> Address �:. !/. / / „ - Phone <br /> U, ner Icity <br /> Contractor's Name °�' 1 <br /> License#-� Business Phone y.��- � VG:V <br /> Contractor's Address _ .(7. k G Sy - y, ,/-- - Emergency Phone r 1 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes I-, No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ O <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT13 <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 <br /> Dia. Casing _ <br />- ❑ DOMESTIC/PUBLIC 11 DRIVEN Gauge <br /> Well of Casing <br /> X IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal _ w <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout _ <br /> ❑ DISPOSAL ❑ OTHER Other Information _ QI <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Purviance Drillers Drilling Corp. �I I <br /> Type of Pump i�tr. ,-; ,,i P. 7S _ <br /> PUMP REPLACEMENT: �/ ® State Work Donee 4- EXT' / 1 rtt o y, <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 Y) <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Ij''fLU) <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 a Grout Inspection prior to grouting and a final Inspection. 1 <br /> Signed X ��% Title: �Y f.S I e,1 t Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By� �. _••�.+ Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final Inspection <br /> \ <br /> Inspection By ' 1 0t Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July i &Received By July 31 <br /> BILLING REMITTANCE REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> r t'7 <br /> OTHER <br /> I,'? <br /> Received by Date Receipt No Permd No. _ Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Do.2009 STOCKTON,CA 95201 <br />