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11-Z Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.: <br /> ,–OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install thework herein described.This application is <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 6697 iJ. Cox Rd City/Town Lr Linden <br /> Owner's Name Ernest W. -Ma;rclano Phone �7— lQ ffW <br /> Address 6697 N Cox Rd City C' <br /> Contractor's Name Clark Well & Equipment License #371560 Business Phone 462-_5 9 7 } <br /> Contractor's Address 2024 E. Charter Way Emergency Phone NA <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL 10 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank '501 __Sewer Lines Pit Privy € <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line +50' Private Domestic Well_ Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL 12 CABLE TOOL Dia. of Well Excavation 12 5/8" <br /> 1 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 8 5281' <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 1Q <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 50' <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout 9 sack mix) <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor oh <br /> Type of Pump H.P. �. <br /> PUMP REPLACEMENT: ❑ State Work Dane <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 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 /> - -Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X r Title: Owner Date: Sept. 2 ,1980 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT'USE ONLY <br /> PHASE I f <br /> .Application Accepted By � ^'- Date <br /> Additional Comments: <br /> P ase t Inspection h Final i spection <br /> 4 <br /> Inspection By /%� Date ��l � f Inspection ByZ�Ay Date <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 i <br /> * REMIT "r <br /> BILLING REMITTANCE $ <br /> EASE EXPLANATION DAMOUNT DUE CHECKED <br /> ATE DATE REMITTED 1 <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY r} <br /> OTHER 1 <br /> OTHER - L <br /> O� F. <br /> Received by DateReceipt No Permit No. suan a Date Mailed Delivered <br /> ,.APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 ;STOCKTON;CA 95201 <br />