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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) I <br /> - <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <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 T.M -R. 7E A,REA, 15 Section 35 City/Town Stockton <br /> Owner's Name Tony Sanchez Phone_ 477-57o6 <br /> Address 18 W Robinhood Dr City Stockton <br /> Contractor's Name Clark Well & Equip.Co . r Inpicense# 76602 Business Phone 462-5597 <br /> Contractor's Address 2024 E. Charter Way Emergency Phone NIA <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❑ open field agricultural <br /> DISTANCE TO NEAREST: Septic Tank 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 J' <br /> 11 <br /> E] 14INDUSTRIAL ® CABLE TOOL Dia. of Well Excavation 'T <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 1411 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 12 <br /> 7 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal none <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <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 ploy persons subject to workman's compensation laws of California." <br /> A"tOpr' t routing and a final inspection. <br /> Signed X Title: vice-president Date: Nov. 8 , 1979 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Datsox <br /> //XZ�7 <br /> Additional Comments: <br /> Phase II Grout Inspection edlliFina nspection <br /> Inspection By 1.4001f Date Inspection Date ��-- <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> --7 S <br /> Received by Date Receipt No. Permit No. Is uance 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 />