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Be Processed When SuAPApplicationsWWiillPLICATION D <br /> = I <br /> FOR OFFICE USE: 4. (For Non-Transferable, Revocable, Suspendable) PUMP&WELL _�_' <br /> 4 )/ <br /> 1 ENVIRONMENTAL HEALTH PERMIT � <br /> r f WATER QUALITYrk n described,This application is is <br /> (COMPLETE IN TRIPLICATE) <br /> all the wo <br /> Application is hereby made to the San Joaquin Local HBalthNost186for dpthe rules and regulattiiions ofythe San Joaquin Local Health District. <br /> made in compliance��San Otrll�unty Ordinance <br /> City/Town French Cam <br /> Exact Site Address Phone none at present <br /> e City same <br /> Owner's Name 5597 <br /> Address 60 Business Phone <br /> Clark Well & E �� ment license#3� NA. <br /> Contractor's Name Emergency Phone {I } <br /> 202 E. Charter Wa No 1" <br /> Contractor's Address } <br /> 1s Certificate of Workman's Compensation Insurance on File With SJLHD? YesDESTRUCTIOND <br /> ® DEEPEN ❑ OTHE ON❑DITI PUMP INSTALLATION ❑ PUMP REPAIR 13 <br /> TYPE OF WORK (CHECK): NEW WELL <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ <br /> REPLACEMENT[] Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank f Other <br /> cesspool/Seepage Pit <br /> Sewage Disposal <br /> .�,Field public Domestic Well <br />'i Property Line�—Private Domestic Well <br /> 8 <br /> TYPE OF WELL 12 'I <br /> INTENDED USE Dia. of Well Excavation „ <br /> 13 INDUSTRIAL not Wei ❑ CABLE TOOL Dia. of Well Casing 8 8 <br /> i ❑ DOMESTIC/PRIVATE 11 DRILLED Class 160 PVC` <br /> EJ DRIVEN Gauge of Casing 0 v <br /> a DOMESTIC/PUBLIC 11 GRAVEL PACK Depth of Grout Seal Bentonite <br /> El IRRIGATION a ROTARY Type of Grout <br /> ❑ CATHODIC PROTECTION ❑ OTHER Other Information <br /> ❑ DISPOSAL Surface Seal Installed By: <br /> ❑ GEOPHYSICAL <br /> Contractor H.P. <br /> PUMP INSTALLATION: Type of Pump <br /> ❑ State Work Done <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> Approximate Depth <br /> PUMP REPAIR: <br /> 1 Well Diameter <br /> DESTRUCTION OF WELL: <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 /> Home owner or licensed agent's signature certifies the following:"1 certify that in the performance nce compensation the work for which this permit <br /> is issued, 1 shall not employ any person in such m III* the fol ow ng: I certifas to become y that nrthe performance ofthelwork{CWl o�this <br /> rl y <br /> Contractor's hiring -coniractin signaiur ertities 5' <br /> per it is 6d, s Il emp p s s sub' t to workman's compensation laws of California." <br /> n ion' ri o g and a final inspection. r 2 <br /> ap-Clark Well & E ui Date: April 7 9 <br /> Title: <br /> i Signed 2 w Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> ti 2 <br /> PHASE 1 pate <br /> Application Accepted y <br /> Additional Comments. Phas 11 Final 1 action <br /> Phase 11 Grout Inspection Date <br /> � Date Inspection By <br /> Inspection By <br /> ❑ Sanuary 1 R Received By January 31 ❑ July 1 &Received By July 31 <br /> Fee Is Due- D ANNUALLY ❑ REMIT UNIT ❑ PER SITE EACH $ AMOUNT DUE CHECKED <br /> BILLING REMITTANCE REMITTED AMOUNT <br /> BASE EXPLANATION DATE DATE <br /> a <br /> FEE T <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER l�� <br /> S Delivered <br /> IL Receipt No Permit No. <br /> lss anc -Date Mailed <br /> Received by Date 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO:- ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />