Laserfiche WebLink
Application B`. 6e Weld l �t S m t �I Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: v ti ICATION es-l' G©,,IP�G. Q.� _ran q <br /> (For Non-Transf , Revocable, Suspendable) , <br /> APR � PUMP&WELL <br /> A ;I <br /> 1 MENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) _11 I; I c:r f- ATER QUALITY l�7 350 <br /> AN JO <br /> Application is hereby madetotheSan Jo vI,k9c 4�� �D�3-fprapermit toconstruct and/or installthework hereindescrib.d.Thisapplicationis <br /> made in compliance with San Joaquin Couu'iin Ordinance o. 1862 and the rules and regulations of the San Jo�a uin Local Health District, <br /> Exact Site Address e City/Town tar r&? ih.rna <br /> Owner's Name Phone <br /> Address P City <br /> Contractor's Name PurvianGetillers Drilling Corp. License#3''J z3 Business Phone <br /> Contractor's Address 6 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ✓ No O 1 <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ r <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other l <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 <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: i/ Contractor Purviance Drillers Drilling Co <br /> Type of PumpI—ar—AI H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <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 /> Home owner or licensed agent's signature certifies the following:1 certify that in the performance of the work forwhich 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 w' call for a r speclion prior to grouting and a final inspection. <br /> Signed X Title: pYgms r en Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> i Application Accepted By Date <br /> Additional Comments: - <br /> t Phase II Grout inspection Phase III Final Inspection <br /> Inspection By 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 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. - Issuarnce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.;P.O.Box 2009 -STOCKTON,CA 95201 <br />