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ppncationsWill Be Processed When Submitted Property Completed. Be S o�Sign The pplication —� <br /> FOR OFFWE USE: APPLICATION � — � f.�, <br /> f, - � <br /> ✓ (For Non-Transferable, Revocable, Suspendable) Q C T 2 2 19$1 <br /> " ENVIRONMENTAL HEALTH (PERMIT A „,f „q PUMP&WELL <br /> LOCAL <br /> (COMPLETE IN TRIPLICATE f C PrP <br /> �t�`���-f1:.=�,;ySf-F+Ec-'—�,J �W TER QUALITY jE,���H �.,,,T:,.�..�T <br /> Application is hereby made tothe Sari Joaquin Local Health district-fora'permit to construct and/or install the work herein described.This application is <br /> �43�Y(���-Q3 <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joagyin Local Health District. <br /> Exact Site Address ,�, �+/ d �'c . <br /> Cit /Town h <br /> Owner's Name <br /> Address O©DPhone ,Pk'l;S <br /> City <br /> Contractor's Name Purviance Drillers License# z <br /> Contractor's Address (t �_ Business Phone <br /> Emergency Phone.. 1 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No pd <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> i WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONXI PUMP REPAIR❑ `4 <br /> REPLACEMENT❑ <br /> l DISTANCE TO NEAREST: Septic Tank - Sewer Lines <br /> Pit Privy <br /> ti *Sewage�Disposal Field Cesspool/Seepage Pit <br /> - Other .� <br /> Property-,Line .Private Domestic Well Public Domestic Well <br /> INTENDED USE _ TYPE OF WELL Q <br /> ❑ INDUSTRIAL '° 4 ' '❑ CABLE TOOLWN' <br /> Dia. of Well Excavation l <br /> ❑ DOMESTIC/PRIVATE DiW.a. of <br /> ❑ DRILLED `7, ..i <br /> ❑ DOMESTIC/PUBLIC r] Well Casing <br /> i; DRIVEN Gauge of Casing _ J <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY <br /> 13 DISPOSAL Type of Grout <br /> ❑ OTHER Other Information <br /> 13 GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Purviance Drilfe s D ' ' <br /> t Type of Pump <br /> PUMP REPLACEMENT: ❑ H.P. <br /> State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL; <br /> Well 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 /> 'Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich this permit <br /> is issued; I shall not employ-ansuch-manner1 p ; <br /> p y' y person in as to":become sub ect to workman's Compensation laws of California." t_ <br /> Contractor's hiring or sub-contracting signature certifies the foilowing:"I certify that in the performance of the work for which this ; <br /> 'permit is issued, I shall employ persorfs'subject'to workman's compensation laws of California.” t <br /> - I will call forG Inspection prior to grouting and a final inspection. <br /> _"` r - - - . <br /> Signed-X <br /> 'Title: <br /> Date: <br /> (Draw Plot Plan o- Date:Side <br /> FOR DEPARTMENT USE ONLY M <br /> PHASEI <br /> Application Accepted By fl. b <br /> Additional Comments: Date 1 1 <br /> Phase"It Grout Inspection Phase III Final inspection <br /> Inspection By pate Inspection By Date /U Z 7l - <br /> Fee Is Due: ElANNUALLY PER UNIT © PER SITE ❑ EAC ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE 'EXPLANATION BILLING REMITTANCE $ REM T <br /> BATE DATE . REMITTED AMOUNT DUE CHECKED <br /> FEE <br /> AMOUNT <br /> LESS <br /> PRORATION f <br /> PLUS <br /> PENALTY <br /> OTHER t <br /> At <br /> OTHER t <br /> Received by Date Receipt NoL Permit No: # <br /> Issuance Da a Mailed Delivered j <br /> APPLICANT—RETURN ALL COPIES TO; ENVIRONMENTAL HEALTH PERMIT/SERVICES li <br /> _ 1601 E.HA2ELTON AVE„P.O.Box 2009- $TOCKTON,CA 95201 <br />