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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 /> S <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rul��ss��aan rpgulati s of the San Joaquin Local Health District. <br /> Exact Site Address SEC II T1 R7E ../►`r IVY) ty/Town Stockton <br /> Owner's Name Margaret Lynch Estate Phone (415) 697-5702 <br /> Address 160 Del Centro city Millbrae <br /> Contractor's Name Clark Well & Equipment License# 371560 Business Phone 462-5597 <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 WELL❑ DEEPEN ® RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ in ag field <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 <br /> ❑ INDUSTRIAL 91 CABLE TOOL Dia. of Well Excavation 1614 <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 16" <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing .250 <br /> 0 <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal NA <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 per n in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or b on g gnaturertifies the following:"I certify that in the performance of the work for which this <br /> per is ' su I all p erso s sub' t to workman's compensation laws of California." <br /> 1 or ut io pr' in and a final inspection. <br /> Signed X Title: VP-Clark Well Date:April 29,1982 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By � A DateD° ` <br /> Additional Comments: <br /> Phase II Grout Inspection se I inal Inspection Q2 <br /> Inspection By Date Inspection Date �—�w <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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. IssuanceV�Maileri Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />