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App!Ica tIo snWill Be Processed When Submitted Properly Completed. Be SureTOSign ineAppucat, <br /> f6FF�CE USE: " <br /> APPLICATION <br /> Far Non-Transferable, Revocable,Suspendable) <br /> � PUMP&WELL <br /> y ENVIRONMENTAL HEALTH PERMIT I! <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY ' <br /> 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 <br /> r <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. j <br /> City/Town Stockton <br /> Exact Site Address 2024' East h r <br /> V ! <br /> 5597 <br /> Owner's Name Robert.-Z• Clark Phone j)62- <br /> Address 000 _as! Charter Y city <br /> Contractor's NameC lark Well & E 1 CO Inc License# 01 66Business Phone 6 - <br /> Contractor's Address 2024 E Charter'Wa Emergency Phone <br /> 462-62336 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes x <br /> No <br /> TYPE OF WORK (CHECK): NEW WELL 13 DEEPEN ® RECONDITIONOt DESTRUCTION❑ <br /> WELL CHLORINATION 11 WELL ABANDONMENT El OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 2 s� Sewer Lines Pit Privy + <br /> Sewage Disposal Field_4n2 - Cesspool/See`page Pit Other <br /> 11 y <br /> .r •• t <br /> ublic-Ddmestic Well_/V <br /> Property Line—Private DomesUc"Welll_..�7�'f � t <br /> INTENDED USE TYPE OF WELL 8 rr t <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation Err <br /> ® DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> -....:r.r _: 2 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN `- Gauge of Casing { <br /> 11IRRIGATION El GRAVEL PACK Depth of Grout Seal 0 s € <br /> 11 CATHODIC PROTECTION ❑ ROTARY Type of Grout Bentonite T I <br /> ❑ <br /> ❑ OTHER Other Information t a E DISPOSAL ) Surface Seal Installed By: <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor <br /> ,Type of Pump - <br /> PUMP REPLACEMENT: "+ , H.P. ; <br /> I 11State Work Done <br /> PUMP REPAIR: ❑ State Work Done 3 <br /> Y <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-af.the-SarLJoaquin Local Health Dis4ict �. <br /> - .. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of th"ork forVbich this permit <br /> -fs^immmislil, I shall not employ any person in such manner as to become subject to workman's compensation laws of California.'' <br /> r Contr ctor's hiring or sub-contracting signature certifies the following:"I certify that in the performgnce.o.f_the work,for which.thi _ f <br /> i per i is i""cl_I I employ` rsons s bject to workman's compensation laws of California." <br /> I wil ll for a G ut. -spec rior to outing and a final inspection. 91 .a <br /> Owner 2 Date`,' 7,, 1980 <br /> 1, <br /> Title: <br /> Signed X ` <br /> (Draw Plot Plan on Reverse Side) <br /> OR DEPARTMENT USE ONLY <br /> PHASE <br /> Dat <br /> Application Accepted By <br /> Additional Comments: £ <br /> Phase II Grout Inspection Phase 111 Final s tion <br /> ate <br /> Inspection By Date Inspection By - <br /> i <br /> G <br /> { Fee Is Due: 11 ANNUALLY ElPER�UNIT El PER SITE ❑ EACH [3 January 1 &Receivetl"By Januar' 31 ❑ July.1 &Received By July 31 <br /> $ REMIT <br /> BASE 'EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMkTTED AMOUNT <br /> FEE -- <br /> LESS .F <br /> PRORAT$ON <br /> PLUS <br /> PENALTY ; <br /> 1 '' • <br /> i{? OTHER <br /> OTHER f <br /> s 3 l3 <br /> Received by -Issuance ate^---�rMailed—^ Delivered- <br /> ,APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES -1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />