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f <br /> ~Applications Will Be Processed When Submitted Properly, omp e eBe sure <br /> FOR OFFICE USE: � APPLICATiONn <br /> Sill -. (For Non-Transferable, Revocable, Suspendable} PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE} <br /> r apermit to construct install the work herein described.This application is <br /> Application is hereby made tothe San Joaquin Local Health District fo <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 1 0327 C.apeyrood- of # 10 City/Town Stockton <br /> Owners Name Great Western Real Estate & Development Phone 951-7191 <br /> Address N. Pershin Suite City Stockton <br /> Business Phone 462-559'7 _ <br /> Contractor's Name Clark Well & E ui ment License#---5 60 AT A <br /> Contractor's Address 2024 E. Charter Way Emergency Phone �. <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL® DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR C <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tai 1 50 r __ Sewer Linesa 5� _ Pit Privy d: <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Lined Private Domestic Well Public Domestic Well <br /> i INTENDED USE TYPE OF WELL a 5/81'1f <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 6 81r <br /> 0 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC 11 DRIVEN Gauge of Casing 2 0 r <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> 13 CATHODIC PROTECTION El ROTARY Type of Grout Bentonite <br /> I ❑ DISPOSAL ❑ OTHER Other Information G <br /> ❑ GEOPHYSICAL Surface Seal Installed By: Stowell *k <br /> PUMP INSTALLATION: Contractor StOWEII <br /> 1 <br /> Type of Pump b 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 l have prepared this application and that the work will be done in accordance with San Joaquin 7permit <br /> P ordinances, state laws, and rules and regulations of the San Joaquin Local Health District, <br /> I <br /> Homeowner or licensed agent's signature certifies the following:"I certify that In the performance of the work for which thi <br /> is issued, I shall n em loy any person in such manner as to become subject to workman's compensation laws of California." <br /> r <br /> Contractor's hiri or ub-b-contracting signature certifies the following:"I certify that in the performance of the work for which t Is <br /> k permit i ss all employ person ubject to workman's compensation laws of California." <br /> I will s ction pri u' a final inspe�. <br /> Signed Title: • Date: <br /> ( raw Plot Plan on Reverse Side) <br /> FOR DEP RTMENT USE ONLY <br /> 4 PHASE I SO <br /> f fate <br /> Application Accepted By <br /> Additional Comments: <br /> Phas II Grout In pectin Ph a Itl Final Inspection <br /> Inspection By Date 1— to Inspection By Date <br /> C Fee Is Due: ❑ ANNUALLY ❑ PER UNIT i$PER SITE ❑ EACH ❑ ,January 1 &Received By,lanuary 31 ❑ July 1 &Received <br /> By July 31 <br /> - BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> r `Y LESS <br /> PRORATION - <br /> PLUS <br /> t PENALTY <br /> OTHER <br /> OTHER <br /> 9a� <br /> ' Received by - Date - Receipt No. Permit No. I suance ate -Mailed Delivered <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES _ <br />