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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> - (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL'HEALTH PERMIT <br /> WATER QUALITY ✓ t�2D�-L <br /> (COMPLETE IN TRIPLICATE)j?:g6o'c ' C a�E�&Al 1 Q ., �,� .7. — <br /> Application ishereby mad etothe��`anJoaquinLocalHealthDistri rapermittoconstructand/or installiheworkhereindescribed.Thisapplicationis <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 Ji mile East-2 mile South C.opperopolls, kity/Town Pete`r,s <br /> =Precessi-,.Lou I ,o� Rd Phone'_ 369-4508. <br /> Owner's Name ` <br /> Address 22 S Avena Ave ;>.. City, Lodi <br /> Contractor's Name Clark Well & _- - <br /> ..Equipment License* '3 4 2-5597, <br /> '71560 Business.Phone : <br /> _ r <br /> Contractor's Address 2024 -E; °Charter Way- � ,, 'Emergency Phone ' rfi NA - <br /> kIs Certificate of Workman's Compensation Insurance-on File With SJLHD? Yes No �µ <br /> TYPE OF WORK(CHECK): NEW WELLKI --DEEPEN ❑ RECONDITION 13 - DESTRUCTION❑ �.G.- <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR© �A <br /> N REPLACEMENT❑ in Open Pasture .field <br /> DISTANCE TO NEARE=ST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL 681 <br /> 1 <br /> t ❑ INDUSTRIAL, ❑ CABLE TOOL Dia. of Well Excavation It <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing VI-0 <br /> 1:1 ❑ DRIVEN Gauge of Casing 12 Steel <br /> 91 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal none <br /> C3 .0 <br /> ❑ CATHODIC PROTECTION M ROTARY Type of Grout <br /> r ❑ DISPOSAL ❑ OTHER Other Information <br /> e� <br /> ❑ GEOPHYSICAL Surface Seal installed By: <br /> PUMP INSTALLATION: Contractor <br /> I Type of Pump H,P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State''Work Dane <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> . Describe Material and Procedure <br /> -" l 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 /> s F <br /> is issued. I shale y ny erson in such manner as.to become subject to workman's compensation laws of California." <br /> •tcontractor's hir su n ac ngsig ture certifies the following:"I certify that in the performance of the work for which this <br /> �j perm' i sue I I e play p sons bject to workman's compensation laws of California." <br /> I �f r r c it routing and a final inspection. <br /> 4r ,Signed X <br /> Title: VP-Clark Well Date:April 2 ,198 <br /> `� (Draw Plot Plan on Reverse Side) <br /> �• �' "" + FOR DEPARTMENT USE ONLY <br /> a <br /> `PHASE i �# <br /> ` Application Accepted By Date <br /> Additional Comments: <br /> Phase II:Grout Inspection ase III F' ` <br /> i Inspection 13y�' f- Date - ?- Inspection By <br /> # . <br /> Fee I's Due: ❑ ANNUALLY ❑ PER`UNIT" ❑ PER SITE []-'EACH ❑ Jae�ary Received By January 31 July 1 &Receiv REMI I 31 <br /> f g .BILLING REMITTANCE _ $. AMOUNT DUE CHECKED <br /> BASE"' s iEXPLANATION DATE ; .DATE 'R IT D AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS ' f <br /> i PENALTY_. q <br /> OTHER <br /> OTHER <br /> Received by <br /> Date ' `Receipt No. Permit No. Fssuanc ate Mailed Delivered <br /> I APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />