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F Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION (ForNon-Transferable, Revocable,Suspendable) PUMP WELL ENVIRONMENTAL HEALTH-PERMIT (COMPLETE IN TRIPLICATE) ,WATER QUALITY,, C Application is hereby made to the San Joaquin Local Health District for a_,r.'.1. ermit 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 '51, ri r -Y City/Town 'Stockton Owner's Naive ('tom i lOr_nila: 1116 ding"SlWply. CO' 1' {^" Phone' tom'- :> 466-8604- Ad d ress 66-8604Address '' Cif "rt Stockton _ y7, Contractor's Name Clark Well EquipmentIL'.icense# '371560:--Business Phone".462- 5 59 Z. Contractor's Address 2024 R., C;h2l -ter.WAV '"� � Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No Y TYPE OF WORK (CHECK):- NEW WELL @' DEEPEN ❑ RECONDITION❑'~ DESTRUCTION❑ WELL CHLORINATION IJ WELL ABANDONMENT ❑, OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: SeI - Tank Property g weG LineSewer-Wellllt `Oyr Industrial Wash t r i S" age Disposal.Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE i TYPE OF WELL W4 INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 0 8r1 ❑ ETI /PRIVATE �a ❑ DRILLED Dia. of Well Casing I .6' 8" DOM S ng C _ ❑ DOMESTIC/PUB_LIC ll ❑ DRIVEN Gauge of Casing # 12 %Steel -- ❑ IRRIGATION ,. ,, ❑ GRAVEL PACK s Depth of Grout Seal 50 v " ❑ CATHODIC PROTECTION-�� ROTARY Type of Grout Bentonite ❑ DISPOSAL �! El OTHER - Other Information l ❑ GEOPHYSICAL Surface Seal Installed By: 4 PUMP INSTALLATION- '°` l Contractor f r W Type of Pump H.P. : ` PUMP REPLACEMENT: State Work Done 1 - PUMP REPAIR: l ❑ State Work Done ' DESTRUCTION OF WELL: I Well Diameter Approximate.Depth { Describe Material and.Procedure - rn 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. Homeowner or licensed agent's signature certifies the fallowing:"I certify that in the performance of the work for which this permit -is issued, I shall not.employ any person in such manner-as to become subject to workman's compensation laws of-California." Contractor's hirin su - nt cling signature certifies the following:"I certify that in the performance of the work for which this permit is issued, all e y erso subject to workman's compensation laws of California." ` I VJ&II t Sp ch pr grouting and a final Inspection. 4— Signed X Title: VP-Clark We 11 8r E4UiD Date: A71aril 10 ,1981 (Draw Plot Plan on Reverse Side) l� FOR DEPARTMENT USE ONLY PHASE I r Application Accepted By Date �1� Additional Comments: �I ` Phase II Grout Inspection ` Phase III Final InspectipA Inspection ByDate Inspection By d Fee Is Due: ❑ ANNUALLY`11 ❑ PER UNIT ❑ PER SITE ❑ EACH ❑"January 1 &Received By January 31 ❑ July 1 &Received ByJuly31 II BILLING REMITTANCE $ REMIT BASE EXPLANATION PATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE LESS PRORATION s PLUS I� f PENALTY 1 OTHER " �:- ��i; ' OTHER a �I JI ' P Received by f Date Receipl No. Permit-No.-a ssuanc Date.: Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 f :II --