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ApplicationsWillBeProcessedWhenSubmittedProperlyCompleted. tie Surero sign TheApplicailon. <br /> FOR 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 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 San Joaquin Local Health District. <br /> Exact Site Address 800 E. Woodbridge Rd City/Town Woodbridge <br /> Owner's Name Woodbridge Golf & Country Club Phone 368`6100 <br /> Address P. oaox 8o6 City Woodbridge c <br /> Contractor's Name Clark Well & Equipment License # 371560 Business Phone 4b2-5597 <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 WELt31 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ , <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ on Golf Course <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other.)' * Mokelumne <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL 22� <br /> 1:1 INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> 12 3/4" <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing .188 Steel <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal// 50' <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout l 9-sack mix (Sand & cement) <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: !7h <br /> PUMP INSTALLATION: Contractor n <br /> Type of Pump H,P, <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County 0 <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. 0 <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit n <br /> is issued, i shall not employ any person in such manner as to become subject to workman's compensation laws of California." 1. <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> pA"is <br /> y pers ns subject to workman's compensation laws of California." <br /> Iti n 1 gr ' g and a final inspection. '— <br /> Signed X Title: VP-Clark Well & Equip Date: May 10,1982 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By ��'�� Date <br /> Additional Comments: 2— Zl- <br /> Phq§e 11 Grout Ins a tion Phase III Final Inspection <br /> Inspection By Date '�2' Inspection Bye Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> .P - , REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE �? O B <br /> LESS <br /> PRORATION -, <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Q Y <br /> Receives!by Date Receipt No. Permit No. lissuan6e 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 />