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Application i riI a mltted Properly Completed. Be Sure To Sign The Application. TR_FOR OFFICE USE: ('( 1� PPLICATION U ��IJJJ (,,Foor��Nt� on- sferable, Revocable, Suspendable) / ENVIRONMENTAL HEALTH PERMIT PUMP&WELL COMPLETE IN TRIPLICATE �y LpCAL WATER QUALITY ^ Application is hereby made to thelsA"agjt `� nctforapermittoconstructand%orinstallthework herein described.This application is r e No� made in compliance wjth San Joafqu ��}n�y�r nce No. 1862 and the rules and regulations of the San Jpaquin Local Health District. Exact Site Address-�2 inti ly.n 14,, Z 6 - Al.L, L., - City/Town Il�P r1 gr � o rhOwner's Name J L. )5O�' o Phone "` Address 254�4S Ak; 2 6 r7 City Lindell Contractor's Name Purviance DrillersLicense#J1 1 923 Business Phone Qd Contractor's Address !nde_e7,!ff:2 36 Emergency Phone t Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ✓ No r� TYPE OF WORK (CHECK): NEW WELLX] DEEPEN ❑ RECONDITION❑ DESTRUCTION P WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION Sr PUMP REPAIR❑ REPLACEMENT❑ 11- DISTANCE DISTANCE TO NEAREST: Septic Tank .2 Mini. Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL 1 A/ ❑ INDUSTRIAL ' Q Q CABLE TOOL Dia- of Well Excavation Rr DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing IRRIGATION ❑ GRAVEL PACK Depth of Grout Seali ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout C ❑ DISPOSAL ❑ OTHER Other Information ElGEOPHYSICAL p Surface Seal Installed By: PUMP INSTALLATION: M' Contractor Type of Pump ✓ H-P. +. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure 'I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Homeowner or licensed agent's signature.certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this permit is issued, I shall employ persons subject to workman's compensation laws of California." I will call for a r I l ection priorao grouting and a final inspection. Signed XTitle: Date: (Draw Plot Plan-on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I Application Accepted By �'' � Date # Additional Comments: e irt Inspection Rhase III Final inspection G� t Inspection B Date Inspection B Date r�16- 3 Fee Is Due: ❑ A41-1 A L L I ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 B Received By January 31 © July 1 $Received By duly 31 BILLING REMITTANCE $ REMIT BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE $$ <" J, LESS PRORATION PLUS PENALTY OTHER OTHER 3 �3 -a Received by Date Receipt No. Permit No. Issiliance D to I Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 111 HAZELTON AVE.,P.O.Sox 2009 STOCKTON,CA 95201 }