Laserfiche WebLink
" Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: - - APPLICATION <br /> (For Nan-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health District'fora permit toconstruct 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 /> Exact Site Address Lot #7 Ca ewaod Estates City/Town Stockton ' <br /> owner's Name GreataWestern Real. Estate &. Dev Ptorie.j f 951,-7191 p <br /> Address _5713 N. Pershing Ave.. ,Suite E city.* StOCkton, C� C <br /> Contractor's Name Clark Well, -& Equipment ',Libense#371.560 , Business P.hbne- 462:-5597r <br /> Contractor's Address 2024 F.­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 0 ' DEEPEN ❑ 'RECONDITION❑ DESTRUCTION❑"'""" <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑. PUMP REPAIR❑ 1 <br /> REPLACEMENT❑ 1 ¢ i <br /> DISTANCE TO NEAREST: Septic Tank +l 00 Sewer Lines ��40 Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line_._..,"0_a_ Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 10 " <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 6 8" <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 12 <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 5101 . <br /> f ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout Bentonite <br /> I ❑ 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. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> I 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 orsub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I sh mp o s su 'ect to workman's compensation laws of California." <br /> I w fo Gr t p n r o ou ing and a final Inspection. <br /> Signed X Title: VP-Clark Well & Equip Date:. De 1 7 . 1880 <br /> (Draw Plot Plan on Reverse Side) <br /> v <br /> FOR DEPARTMENT USE ONLY i <br /> PHASE I <br /> I <br /> Application Accepted By Date <br /> f <br /> Additional Comments: <br />! Phase 11 Grou 1 Spec on Phase III Final Inspection I <br /> InspectionBy Date Inspection By = Date <br /> Fee Is Due: 11"ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH, O'January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING , REMITTANCE $ <br /> BASE EXPLANATION AMDUN7 DUE CHECKED <br /> DATE DATE REMITTED aT r t AMOUNT <br /> FEE <br /> LESS 1 C+ <br /> PRORATION <br /> PLUS <br /> E <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 7 <br /> Received by Date Receipt No., Permit No. - Is ance ate Mailed Delivered <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1501 E.HAZELTAYE.,P.O.Box 2009 STOCKTON,CA 95201 <br />