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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. F. R °F1=acE USE: APPLICATION (For Non-Transferable,Revocable, Suspendable) �IJMP �J ENVIRONMENTAL HEALTH PERMIT &WELL {COMPLETE IN TRIPLICATE) ,� r TER QUALITY p.� L �� .�-:S '. r — -,.. , .f• L. , r *w 3 fn ...,. '. 127—! —' 6�-0� Application is hereby made to the San Joaquin Local Health Dist ict fora permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No. 1862 and they rules and regulations of the San Joaquin Local Health District. Exact Site Address ' Mile South"'of Little John "Creek on City/Town Stockton Owner's Name - 2-41'-D. -".BUD:',-%REYNOLDS -Stanley Road - Address Address 6 out h ' _`;St nle o ' - . - Phone City Stockton, Contractor's Name Clark Well 81 Ea Ul Ment_ License41715_60 462- Business Phone. Contractor's Address Charter " n'rt"`(_" ' Emergency Phone N Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X — No 011 TYPE OF WORK (CHECK): NEW WELLZ '_DEEF�EN ❑ T RECONDITION❑ _ DESTRUCTION❑ WELL CHLORINATION ❑- WELL ABANDONMENT ❑ OTHER ❑ REPLACEMENT❑ PUMP INSTALLATION ❑ PUMP REPA IRE] DISTANCE TO NEAREST: Septic Tank. Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other " Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL 11 CA13LE TOOL Dia. of Well Excavation 12" ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 12'r ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing . 188 MIRRIGATION ❑ GRAVEL PACK bl Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY :Type`of Grout # �l r❑ DISPOSAL 'El OTHER `Other Information r ## TA GEOPHYSICAL- : _ . Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter t 1 Approximate Depth Describe Material and Procedure I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state laws, and rules and regulations of the Saw-,Joaquin Local Health District. i Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit , is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." ' ' Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work torwhich this { permit is issued, I shall employ persons subject to workman's compensation laws of California," I will call for a Grout Inspection prior to grouting and a final=inspection. Signed X 1 '''f Titie. . `/'��'`��''� _ Date: 1 Feb 81 {Draw Piot Plan on Reverse Side} " FOR DEPARTMENT USE ONLY PHASE l ��"�•--.' Application Accepted lPhase- Date f Additional Comments: i h _ ut Inspection Inspection Bye K� --r Date 7 Phase III Final Inspection Inspection By. _ Date Fee Is Due: ❑ � l�� I ANNUALLY ❑ PER UNIT ❑ PER SITE' ❑ EACH ❑ January 1;8 Received By J ar 31 y El 1 8 Received By July 31 BASE EXPLANATION- BILLING REMITTANCE y $ REMIT DATE DATE REMITTED AMOUNT DUE CHECKED ti AMOUNT . FEE # LESS- PRORATION - PLUS PENALTY - OTHER OTHER Received by Date Receipt No - �._ .. ' permit No. _ _-ssuanc pat 3 Mailed Delivered J!d{ APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201