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-� Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ,FOR OFFICE USE: APPLICATION <br /> pp (For Non-Transferable, Revocable, Suspendable)-- <br /> pOMp&WELL <br /> F. <br /> ENVIRONMENTAL HEALTH PERMIT =! <br /> F J WATER QUALITY(COMPLETE IN TRIPLICATE) r <br /> Application is hereby madetothe San Joaquin Local Health Districtfor-a 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 rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address _9222 Valley Drive _ City/Town Stockton <br /> Owner's Name Al Darrah + Phone 931.-1342 4; <br /> Address 9222 Ylle-y Dri_v_e City Stockton, CA 9 5212 ____S>1 <br /> Contractor's Name Clark Well & Equipment License# 371560 Business Phone, 462-5597 � <br /> Contractor's Address 2024 E Chi_tg�. W2.� STKN Emergency Phone N�A <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL 91 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> +�+ REPLACEMENT❑ i <br /> I DISTANCE TO NEAREST: Septic Tani 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 .10 <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 12 <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 501 <br /> ► ❑ CATHODIC PROTECTION ROTARY Type of Grout Bentonite <br /> ❑ DISPOSAL 1 OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. F <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> t �- <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> a. <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 /> i is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> i - <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 Califs ia." <br /> I will call <br /> //for//a Grout <br /> tI�Inspection prior to routing and a final inspection. <br /> Signed X t/LJ�i I�y,��� Title: Owner Date; 27 August 1980 <br /> LLL. (Draw Plot Plan on Reverse Side) <br /> FOR DE ARTMENT USE.ONLY <br /> PHASE I <br /> Application Accepted By "^ Date <br /> Additional Comments: <br /> Phase II Grout Inspection C Ph s I I Final Inspection <br /> I inspection By- &Jgate �_a I ^�� _ Inspection By Date <br /> i <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 &Received By Juiy 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> - BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> t AMOUNT <br /> a <br /> { FEE 'Y3 0 <br /> LESS <br /> p PRORATION L <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER � /{ - <br /> 1` !�/V Z1] <br /> i <br /> Received by Date g Receipt No. Permit,No. - I uance Date Mailed Delivered <br /> APPLICANT—RETURN-ALL COPIES TO: r ENVIRONMENTAL HEALTH PERMIT/SERVICES R 1601 E.HAZELTON AVE,,P.O.Bol 2009 STOCKTON,CA 95201, <br />