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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. Y#� FOR,OFFICE USE: APPLICATION ` (For Non-Transferable, Revocable,Suspendable) PUMP&WELL la ENVIRONMENTAL HEALTH PERMIT w k (COMPLETE IN TRIPLICATE) WATER QUALITY _ ,. Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.Thisapplication 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 12022 Comstock City/Town Ctnckton Owner's Name V -7"'Tion kava Phone 477--2-3-36 Address 2359 Sheridan Way City Stockton Contractor's Name Clark Well & Equipment License#37-15 60 Business Phone 462-5597 Address 2024 E. CharterEmergency Phone NA kIs Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELLZ DEEPEN ❑ RECONDITION ElDESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank +100' Sewer Lines Pit Privy - I Sewage Disposal Field +10() Cesspool/Seepage Pit Other Property Line +100 Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation_ ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 8 Vic//g°1 t WL DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 12 Steel- 11❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 50# ❑ CATHODIC PROTECTION ROTARY Type of Grout _ Rantonite r ❑ DISPOSAL ❑ OTHER _ 'Other Information ❑ GEOPHYSICAL Surface Seal installed By: I PUMP INSTALLATION: Contractor Type of Pump H.P. [[ PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure i 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. Homeowner or licensed agent's signature certifies the following:"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 'ring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this permit 's is ed, I shall employ persons subject to workman's compensation laws of California." I wt for a Grout Inspec P' n pri to grouting and a final inspection. Signed X Title: O=er Date: (Draw Plot Plan on Reverse Side) ' FOR DEPARTMENT USE ONLY �1 PHASE f Application Accepted By rEi Date Additional Comments: F Phase II Grout Inspection h e I11 Inspection Inspection By efe — '-� Date 1___116 � Inspection By e Date y Fee IS Due: ❑ ANNUALLY ❑ PER UNIT -❑ PER SITE ❑ EACH ❑ January 1.&Received By January 31 ❑ July 1 &Received By July 31 REMIT i BILLING REMITTANCE $ f BASE' EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED ` AMOUNT FEE 4 LESS PRORATION .PLUS PENALTY r OTHER OTHER P Received by Date Receipt No. Permit No Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES'__-----_1601 E.HAZELTON AVE.,P.O.Bo.2009 . STOCKTON,CA 95201