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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) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WALL <br /> (COMPLETE IN TRIPLICATE) r 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 /> made in compliance with San Joaquin County Ordinance No.1862 and the rules and regulations of the Sano ui cal Health District. <br /> Exact Site Address S . Drias City/Town � ` � <br /> Ct°on <br /> Owner's Name Mr• A• Pa,StOrl Phone <br /> 2- 3?0 <br /> Address 9 51 S . DriasC;ty oc on <br /> Contractor's Name Clark Well & Equip. License#371`T1"" Business Phone — , <br /> Contractor's Address 202 E. Charter Way Emergency Phone NA i <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL® DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ , <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank +50' Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well 101 Public Domestic Well WV <br /> INTENDED USE TYPE OF WELL 10 5/84F <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> � DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> 5/8 ir <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing =12 steel <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 501 <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout Bentonite <br /> ❑ DISPOSAL ❑ OTHER 'Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H,P. D <br /> PUMP REPLACEMENT: ❑ State Work Done %A F <br /> PUMP REPAIR: ❑ Stati 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 14 <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:1 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 p ns sub'ct to workman's compensation laws of California." <br /> I w' call f rout I spection r' to gr Ing ynd a final inspection. <br /> Signed X C9 I't" Title; Owner Date: July 22 ,198() <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I -- �� <br /> Application Accepted By4( Date <br /> Additional Comment., ZI <br /> ha II Grout I pection � FI hag III sl Inspection d� <br /> Inspection B/; Date 7— Inspection By Date <br /> Fee Is DUE: ❑ ANNUALLY ❑ PER UNIT if PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> RE <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOU <br /> FEELESS fm <br /> /( �I <br /> PRORATION 1J C 5—^ ..w1Q <br /> PLUS �- 5 <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES . 1001 E,HAZELTON AVE.,P.O.Box-2009 STOCKTON,CA 95.201 <br />