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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> _FOFrOFFI USE: APPLICATION <br /> (For Non-Transierable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT ' <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY J <br /> Application is hereby made to the San Joaquin Local Health Districtforapermit toconstruct and/or install the work herein described.This application is <br /> made in compliance with San Joa n County Ordinance No.1862 and the rules and regulations of the San Joaquin Local Health District <br /> Exact Site Address__LOtTJeWOOC� ESt-. eS—IVIDr'ac a City/Town Stockton I <br /> Owner's Name V Phone 171 . 1 <br /> Address — 1�71 3 UJ City Sonktn 2 <br /> Contractor's Name Clark Well & Equip_ License#3 1 60 Business Phone 462-559 <br /> Contractor's Address 70 -4� F.. Charter Wa_V - Emergency Phone NA I <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL U DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ ( } <br /> REPLACEMENT❑ J <br /> DISTANCE TO NEAREST: Septic Tank ± 50* Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other �. <br /> Property Line +10* Private Domestic Well +35' Public Domestic Welt <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 10 5Z8 <br /> U DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing _ 11 6 5/811 <br /> -0 DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing it 12 Steel � <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 5011- <br /> 11 <br /> 0n❑ CATHODIC PROTECTION 0 ROTARY Type of Grout 9—Sack mix <br /> ❑ DISPOSAL ❑ OTHER Other Information , <br /> ❑ GEOPHYSICAL Surface Seal Installed By: Stowell <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 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. Y <br /> c <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit e <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> t <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 s emp rsons sub' ct to workman's compensation laws of California." <br /> 1 11 10 r s to t ng and a final inspection. ,— <br /> Signed X . Title-. VP-Clark Well Date: Oct. 16, 1981 <br /> r (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY i <br /> PHASE I ®/ <br /> Application Accepted By Da Date lG~rte yl <br /> Additional Comments: <br /> __Phase 11 Grout I spection Phase III Final Inspection <br /> Inspection By,^ 7 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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> B <br /> AMOUNT <br /> FEE <br /> .cao <br /> LESS <br /> PRORATION <br /> PLUS .i <br /> k PENALTY <br /> OTHER <br /> OTHER <br /> 1S4's-_7o-Cko4 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered f <br /> k APPLICANT—RETURN.ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE P.O.Box 2009. STOCKTON,CA 95201 _ <br />