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Applications Will Be Processed When'Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION - * A (For Non-Transferable, Revoaable;•Suspendable) Q ilk ENVIRONMENTAL HEALTH PERMIT PUMP&WALL (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of..the San Joaquin Local Health District. Exact Site Address 10356 Ca vood Trot #5 City/Town Stockton Owner's Name Tony A.bdallah Phone Address - City Contractor's Name Clark_ Well & Equip License# 371560 Busin ss Phone 2-507 Contractor's Address 2024 East Charter Way Emergency Phone N/%a Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No a TYPE OF WORK (CHECK): NEW WELL® DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy _ Sewage Disposal Field Cesspool/Seepage Pit Other, +•- + _ Property Line Private Domestic Well Public Domestic Well INTENDED USE- TYPE OF WELL 13INDUSTRIAL 11CABLE TOOL Dia. of Well Excavation--AID M.bO-MESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 60 ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing OIL ❑ IR6*�GATION ❑ GRAVEL PACK Depth of Grout Seat ❑ CATHODIC PROTECTION 91 ROTARY Type of Grout �L1TaN�lTE t'� ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Dane PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth , Describe Material and Procedure I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich this permit is iss I shall no loy any person in such manner as to become subject to workman's compensation laws of California." C 'tract fs hirin or sub o ratting signature certifies the following:"I certify that in the performance of the work for which this r P i is�ued, I shall I persons subject to workman's compensation laws of Ca' jnia',Cj�,I I call fr a Gr spe ti n prior to gro nd a final inspection. Signed X Title: "' ate: I® ( aw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY -- - PHASE I f;,, - /} Application Accepted By w1�� Date � 18 Additional Comments: Ph a II Grout Inspection ) Phase II Final Inspection Inspection By. Date ( _3+::�Rb Inspection By Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 7 B.Aeceived'By January 31 -❑ Juiy 1 &Received By July 31 REMIT BILLING REMITTANCE $RASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE g i 3 LESS PRORATION PLUS PENALTY OTHER i OTHER Received by Date Receipt No. Permit No. Is ante D to Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 ,