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Mi 2 1 IUN <br /> `l9)Non-Transfer8bIe, Revocable, Suspenclable) <br /> I-2-LS-0 F. AAC�G4 0"_ /70-6?.( PUMp&w <br /> ELL <br /> lk <br /> e7l SAN C.--U kN PERMIT <br /> ,Y)RONMENTAL HEALTH <br /> & <br /> 17 e— 36�14YJ <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATES HEAL TH", Di T iR�i k- <br /> Application is hereby made tothe San Joaquin Local Health District fore permitto construct and/or install thework 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 /> - <br /> Exact Site Address L5001f M1411L --2519' -32 City/Town <br /> Owner's Name Dan r4ndsZ,-,d Phone 0G <br /> Address 0, ,�a 9-4 is k,V City <br /> Forviance Drillers Drilling Corp. <br /> Contractor's Name License tt3_11%Z3 Business Phone <br /> Contractor's Address P 0, dee, Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 1,_ No <br /> TYPE OF WORK(CHECK); NEW WELL 0 DEEPEN 13 RECONDITION 13 DESTRUCTION 0 <br /> WELL CHLORINATION D WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONA PUMP REPAIR 13 <br /> REPLACEMENT 13 <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 /> 11 INDUSTRIAL 0 CABLE TOOL Dia. of Well Excavation <br /> 0 DOMESTIC/PRIVATE 11 DRILLED Dia. of Well Casing <br /> C1 DOMESTIC/PUBLIC 0 DRIVEN Gauge of Casing <br /> IRRIGATION 0 GRAVEL PACK Depth of Grout Seal <br /> 0 CATHODIC PROTECTION 11 ROTARY Type of Grout <br /> 0 DISPOSAL 11 OTHER Other Information <br /> 0 GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: &---- Contractor—Purviance Drillers Drilling _Ccirp. <br /> Type of Pump— TU[L A, — H.P. -5 <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth t\ <br /> Describe Material and Procedure A <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 /> 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a ro n action prior to grouting and a final inspection. <br /> Signed X T Title: r-Pr Date:, <br /> (Draw Plot Plan on Reverse Side) <br /> I FOR DEPARTMENT USE ONLY <br /> PHASE <br /> �, <br /> Application Accepted By Q0,2, Dated C <br /> Additional Comments. <br /> Phase 11 Grout InspectionI Inspection <br /> a <br /> Inspection By— Date Inspection By Date 6`2—9�_ <br /> Fee Is Due: 11 ANNUALLY El PER UNIT 0 PER SITE 13 EACH 0 January I &Received By January 31 El Jury 1 &Received By July 31 <br /> SILTING 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 /> OTHER <br /> n <br /> Received by Date Receipt No. Perrn+l No. issuance Dale mailtdDelivered' <br /> L___� APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.HAZELTON AVE..P.O.Box 2009 STOCKTON,CA gs201 <br />