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ApplicationsWillBeProcessedWhen Submitted ProperlyCompleted Be SureToSignTheApplication. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (L.3MPLETE IN TRIPLICATE W TER QUALITY "^^ 4S F," <br /> 1 , d7 nI,•. C-Pi�o Ors- zro -�o /^ <br /> Application is hereby madeto th San Joaquin Local Health District fora errt7it to construct and/or install the work herein described.This application ,-r <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 _Woodbridge Sanitary District Plant City/Town Woodbridge <br /> Owner's Name Woodbridge Sanitary District Phone None <br /> Address P o. Box 299 City Woodbridge <br /> Contractor's Name Clark Well & Equipment License# 0 Business Phone 462-55- 7 <br /> Contractor's Address 2024 E. Charter Way Emergency Phone - nar2P r <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK); NEW WELLZI DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> 1501 to sewer percolation ponds <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy j <br /> Sewage Disposal Field Cesspool/Seepage Pit Other f <br /> Property LinePrivatePrivate Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 12 548 <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing t8 8 <br /> 11jf <br /> �(1 <br /> ® DOMESTIC/PUBLIC DRIVEN Gauge of Casing 10 �1 <br /> ❑ IRRIGATION 11 GRAVELPACK Depth of Grout Seal 0 - <br /> ❑ CATHODIC PROTECTION 91 ROTARY Type of Grout Bentonite <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump &2!a H.P, �- I <br /> PUMP REPLACEMENT: ❑ State Work Done i <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure ,T <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 /> Home owner 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I w' c I for G 1 srior routing and a final inspectio <br /> Signed X Title: �_ Date: r V <br /> (Draw Piot Plan on Reverse Side) r <br /> FOR DEPARTMENT USE ONLY # <br /> PHASE 1 <br /> Application Accepted By Date Y <br /> Additional Comments:-.-. .. .. <br /> Phase II Grout Inspection�1 Phase I { Inspection J <br /> Inspection By Date cf-`oZ1 $C� Inspection By .RAV Z- t. Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January i &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> 00 <br /> LESS <br /> t PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> eceived by Dae /Receipt No. Permit No. Issuance 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 />