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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication. <br /> FDR OFFICE USE: APPLICATION <br /> (For Non-Transferable,Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) <br /> WATER QUALITY ,;,r , r* r T;° l'� <br /> Application is hereby made to the San Joaquin Local Health District for a permit to constructand/orinstallthework herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulatipns of the San JotagCktOn quin Local Health District. <br /> '10250 Childress city/Town <br /> Exact Site Address <br /> ,.. ;, � �, � , Phone �'-160 _ <br /> Owners Nanie Allen Maxon City Stockton,, Ca 212 <br /> 102 0 Childress `" = <br /> Address 60 Phone'!' X62-5597 ; <br /> Contractor's Name Clark Well, & 'E ui ment,; License#J11-5— Business <br /> " N/A <br /> Contractor's Address <br /> 202 E-Charter Way w "Emergency Phone',� � No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD. Yes <br /> TYPE OF WORK (CHECK): NEW WELL 93 DEEPEN'❑ -RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ - WELL ABANDONMENT ❑ OTHER C3 PUMP.INSTALLATION El PUMP REPAI 9 <br /> REPLACEMENT© _ IUe <br /> DISTANCE TO NEAREST: Septic Tank 70 Sewer Lines 80s Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well 10 Public Domestic Well e <br /> INTENDED USE TYPE OF WELL <br /> 10 8" <br /> El INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 6 5 811 <br /> ® DOMESTIC/PRIVATE 11 DRILLED Dia. of Well Casing 2 <br /> ft 11DOMESTIC/PUBLIC 13 DRIVEN Gauge of Casing <br /> 13 IRRIGATION 11 RAVEL PACK Depth of Grout Seal Cement Groin <br /> 11CATHODIC PROTECTION COY ROTARY TYP oe f Grout <br /> ""'-""""""""'�" �"-- ❑ OTHER Other Information <br /> ❑ DISPOSAL <br /> i ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor : <br /> ' Type of Pump " H.P. S r <br /> C3 State Work Done <br /> PUMP REPLACEMENT: <br /> PUMP REPAIR: ❑ State Work Done - r e -Well Diameter " w Approximate..pepth <br /> DESTRUCTION OF WELL: r t T I <br /> Describe Material and Procedure yy f - <br /> A tri' <br /> ' I hereby certify that I have prepared this application and that the work will be,done in.accord Ice with San JoagJlin County <br /> ordinances, state laws, and rules and regulations of the San;'J84yin-L'ooI�I�He�lttl gisti!Fi'ct. # ��-- ; r <br /> Home owner or licensed agent's signature certifies the followings I certify iht in the, erformance of ttie work for, <br /> or whichhis permit <br /> is isKe), I shall not toy any person in such manner as to become'sub]I3ot to workman's compensation laws of fyalifornia." <br /> Co tra or s hiring r su -contraciin sighature certifies the following:"I certify that in the performance of the work fot{whh this 1 <br /> per it s issued, I hall mploy er s sub] t to workman's compensation laws of California." <br /> I for a Gro t I C111r i Mgr Ing and a final;insectian. s May 81 <br /> 1 Titlp: .Sec—Tres Clark W611 Date: <br /> Signed X.* <br /> (Draw Plot Plan on Reverse Side) t <br /> f <br /> I FOR DEPARTMENT USE ONLY t <br /> PHASE I F7111 D to 1 <br /> Application Accepted By <br /> Additional Comments: <br /> .,...,-,�. <br /> _Phase II Grout,Inspection , <br /> Inspection B <br /> T7 -��rr Dale -��Y Inspection By a e t <br /> ' <br /> Fee tS Due: ❑ ANNUALLY PER UNIT ❑ PER SITE ❑ EACH '-❑ January 1 &Received By January 31 ❑ July 1 & eceiveRd By l July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DOE CHECKED <br /> DATE DATE REMITTED. AMOUNT <br /> i . <br /> FEE ori • _ <br /> LESS <br /> PRORATION <br /> PLUS' # <br /> PENALTY l <br /> OTHER <br /> t i <br /> OTHER <br /> Mailed Deliered <br /> Received by Date <br /> Receipt N0.- Permit No - Issuance Date * _ <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />