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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. `FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable, Suspendable) .� ENVIRONMENTAL HEALTH PERMIT PUMP&WELL (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby madeto the San Joaquin Local Health Districtfora permitto construct and/or install the work herein described.This application 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 NW Corner of Austin & Arch rd City/Town Stockton Owner's Name Tony Sanchez Phone 477-5706 Address 18 W Robinhood Dr City Stockton Contractor's Name Clark Well & Equip._ License# 76602 Business Phone 462-5597 Contractor's Address 2024 E. Charter Way Emergency Phone NA Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR REPLACEMENT 11 Open field agricultural use 154. 6 acres DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line 201 Private Domestic Well +100 1 Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL 13:CABLE TOOL Dia. of Well Excavation 16" ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 1611 ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 12 10 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal none ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout none ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: 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 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 hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued em loy persons subject to workman's compensation laws of California." I ' c f a s ion r to grouting and a final inspection. SignedX Title:Vice-President,CLARK Date: Oct 17 .1979 (Draw Plot Plan on Reverse Side) FO DEPARTMENT USE ONLY PHASE I fir\ 7 Application Accepted By _ Date v l7 7 Additional Comments: Phase 11 Grout Inspection PI1 I Final Inspection Inspection By Date Inspection By v Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BILLING REMITTANCE $ BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE Q LESS PRORATION PLUS PENALTY OTHER OTHER 7 9—1 l-1-5 1 0/\7/77 Received by Date Receipt No. Permit No. Issuance Date IMailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201