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Appl c6iirbn6"Will'Be Processed Whei�jhmltled Properly Completed.Be Sure To Sign The Appllcatlon. 1 Fo ;o J!ICE USE: SAY IIgg81 APPLICATION �. For Non-Transferable,Revocable,Suspendable) i, PUMP&WELL K I ,UlNENVAbNMENTAL HEALTH PERMIT SAN VI , 11 (COMPLETE IN TRIPLICATE) Hr�J - H DIST RIOT WATER QUALITY "r Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District, . Exact Site Address �.� City/Town e✓../ia d" - Owner's Name M 6 r-1,12a a a it� 0 Phone — Address City I' ^• Contractor's Name Purviance Drillers Drillin Co License#3�/z 3 Business Phone of= f „,•_ Contractor's AddressO jS-113 L Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHDT Yes No C TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN © RECONDITION❑ DESTRUCTION El " WELL CHLORINATION ❑ WELL ABANDONMENT_ ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR 13 " 4 REPLACEMENTIN DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy ^, Sewage Disposal Field Cesspool/Seepage'Pit Other Property Line _Private Domestic Well -Public,Domestic Well - ' INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia.of Well Excavation ® DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing It + IR IRRIGATION ❑ GRAVEL PACK Depth-of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout T, ❑ DISPOSAL ❑ OTHER Other Information T 4 ' ❑ GEOPHYSICAL Surface Seat Installed By: PUMP INSTALLATION: Contractor -Purriance Drillers Drilling"C'brp, Type of Pump H.P. 1A9 PUMP REPLACEMENT: ❑ State Work Done—A �� A / p�-- - --- --- PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter - F Approximate Depth . Describe Material and Procedure, , ,,.•„_ Q) t I hereby certify that 1 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. ”w 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 lo.workman's-eompensat ion.jaws of California." Contractor's hiring orsub-contracting signature certifies thelollowing:"I certify that in the performance ot,the work for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." I j I call for 9 Gr t Inwection prior to grouting and a final Inspection. 4 � Signed X _... - -- - + . G .-lzCDate: �S (Draw Plat Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I j Application Accepted By - �� Date 1 j Aliditional-Comm;nts: `.y - Phase If Grout Inspection PhaIt nat Inspection 'i Inspection By Date. Inspection By Date y��-�� Fee Is Due: ❑ 'ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH (❑ January 1 &Received By January 31 ❑ July 1 8 Received By July 31'l REMIT BAS BILLING REMITTANCE - $ • - E EXPLANAT4oN AMOUNT DUE CHECKED ' • - DATE DATE REMITTED (,�c FEE AMOUNT y CJ LESS 5 PRORATION PLUS - PENALTY F;1[ OTHER It :r OTHER f Received by Dille Aeceipl No. errnil No. i ante ata Mailed Delivered ��t APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTHPERMIT/SERVICES- ' 1691 E.HAZELTON AVE.;P.O.Boa 2009, STOCKTON,CA 25261