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e. App l �tl ngNlWzA-Prdetsftd Y�Phe f� mitted Properly Completed, Be Sure To Sign The Application. <br /> F.0R OFFICE USE: PPLICATICN �ehr-ty� — f�� -�� <br /> y V1AR 22 ININon-Transferable, Revocable,Suspendable) <br /> ENVIONMENTAL HEALTH PERMIT PUMP&WELL <br /> i SAN Ji?,�.�`L'N <br /> LOU. L <br /> (COMPLETE IN TRIPLICATE) I hi C. WATER QUALITY <br /> u� kt Dl T iLT � . .;; 7--Mi <br /> I Application is hereby made tothe 5bh`do InLoca eathDistrictforapermittoconstructand/or installtheworkhereindescribed.Thisapplicationis <br /> made in compliance with San Joaquin County Ordinance No. 186 and the rules and regulations of the San Joa uin Local Health District. <br /> I 3 <br /> Exact Site Address j7�� � �� CTn�i�y/Town itis(er1 <br /> Owner's Name D 11 Phone 621-5,406 10 -0 <br /> Address ��-0, f3aictr City <br /> Nurylance n ers rl)Ting Corp <br /> Contractor's Name License#Sllf. Business Phone <br /> Contractor's Address AI? - [I[ – �.ihde.l Emergency Phone �— <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes r/ No �y <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> I WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONR PUMP REPAIR <br /> REPLACEMENT❑ <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 /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation--__­ <br /> 11 <br /> xcavation _❑ DOMESTIC/PRIVATE ❑ DRILLED pia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> I IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL purf a Seal Installed By: <br /> PUMP INSTALLATION: Contractor Purviance Drillers Drillingorp. <br /> I I_ <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF <br /> .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. ���333 <br /> Home owner or licensed agent's signature certifies the following:-"I certify that in the performance of the work for which this permit L <br /> is issued, I shall not employ C t� <br /> p y person in such manner as-to become subject to workman's compensation laws of California." C <br /> Contractor's hiring or sub-contracting signature certlfles.the following:"I certify that in the performance of the work for which this <br /> permit is issued, I s employ persons subject to workman's i,ompensation laws of California." <br /> Tl.will call for out spection�prior to grouting-and-a.final Inspection. }— <br /> Signed X -� Ski- Title: ��5(�PiZl Date: <br /> (Draw Plot Plan on Reverse Side) -� <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �PAIA <br /> ©�Application Accepted By _ Dat �� <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date ?6 kl <br /> 1 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ J1 &Received By January 31 ❑ July 18 Received By July 31 <br /> BILLING REMI ANCE REMIT <br /> BASE EXPLANATION DATE DATE REMITTED <br /> AMOUNT DUE CHECKED <br /> ----- AMOUNT <br /> FEE <br /> I LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER e — <br /> OTHER <br /> Received by Date Receipl No Permit No. Issuance Date Mailed D.1114rd ! — <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE-,P.O.Box 2009 STOCKTON,CA 95201 F' <br />