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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 /> y PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetotheSan 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 " Atherton Island City/Town Stockton _gv <br /> Owner's Name Atherton Island Homes Association Phone <br /> Address 7 Atherton Iland city Stockton <br /> Contractor's Name Clark Well & Equilp Co InCLicense# 371650 Business Phon 2-5597 <br /> Contractor's Address 2024 E Charter Way Emergency Phone x'62-623 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELLD DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ 1 <br /> DISTANCE TO NEAREST: Septic Tank f 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 <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 1411 <br /> ❑ d DOMESTIC/PRIVATE ❑ 1011 <br /> DRILLED Dia. of Well Casing ..,, <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing Cl 16o <br /> JU IRRIGATION ® GRAVEL PACK Depth of Grout Seal 50 m <br /> ❑ CATHODIC PROTECTION 1 ROTARY Type of Grout Bentonite, <br /> ❑ DISPOSAL ❑ OTHER Other Information ZP <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <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 <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 fo a Grout Inspection prior to grouting and a final inspection. <br /> Signed Title: President Date: 6 March 1980 <br /> (Draw Plot Plan on Reverse Side) <br /> F EPA MENT US ONLY <br /> PHASE IX/_�, <br /> Application Accepted By-9,JDate�)1"�� <br /> Additional Comments: <br /> Phase II Grout Inspectionh �11al Inspection <br /> Inspection Byf Date Inspection By Date <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 & ived By January 31 ❑ July 1 &Received By July 31 <br /> 60- REMIT <br /> BILLING REMITTAN $ <br /> BASE EXPLANATION DATE D REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE ' ✓ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER A <br /> OTHER Q <br /> Received by Date Receipt No. Permit No. fssuanc6 Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />