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Applications Will Be Processed WhenSubmitted ProperlyCompleted. BeSureTo SignTheApplicallon. FOR OFFICE USE: 11 0 APPLICATION (For Non-Transierable, Revocable, Suspendable) ' -'-- PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE)vm��-`'� WATER QUALITY Q�� .�:�"'r� Application is hereby made to the San Joaquin Local Health-Districtforapermit toconstruct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. i Exact Site Address Triangle.. Industrial Park Sta eeoaeh DPCity/Town . o 'P Owner's Name Aberthaw Construction Phone Address 465Forbes Boulevard citySouth San-F�anc_isco . �a �LnRn Contractor's Name Clark Well & Equip License# 371560 Business Phone 462-5597- Contractor's 62-5597- Contractor's Address 202 ' E 'Charter Way Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X _No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ O WELL CHLORINATION ❑ WELL ABANDONMENT M OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR El .l REPLACEMENT© �l1/ GpON rlpL,O- 0161ZOA-0 nouk •3 U�L� C�(�� S�r�� i DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy —ZSewage Disposal Field Cesspool/Seepage Pit Other a Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL `r} ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation— 0 G• ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC I� ❑ DRIVEN Gauge of Casing Z ❑ IRRIGATION I ❑ GRAVEL PACK Depth of Grout Seal 3 r ❑ CATHODIC PROTECTION II ❑ ROTARY Type of Grout 5, SA ❑ DISPOSAL ❑ OTHER Other Information ; ❑ GEOPHYSICAL Surface Seal Installed By: k� n�1 PUMP INSTALLATION: I Contractor ` Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: I ❑ State Work Done DESTRUCTION OF WELL: Well Diameter - Approximate Depth ?�{� Describe Material and Procedure T I i 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,l and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich this permit I 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 su -c acting signature certifies the following:"I certify that in the performance of the work for which this i w permit is issued, s Il emplo s subject t workman's compensation laws of California." r e'n' I I r a u I r grou ' g and a final inspection, y '! Signed Title: Vice-Pres , Clark Well Date: i6 Sep 80 j (D Plot Plan on Reverse Side) FORD PARTM T USE ONLY r PHASE I Application Accepted By '� Date LS� � Additional Comments: l` Phase It Grout Inspection Phase Ili Final Inspection Inspection By Date � Inspection By Date Fee Is Due: 13ANNUALLY .,p. ❑ PER UNIT LB PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 I BILLING REMITTANCE $ REMIT BASE'! EXPLANATION AMOUNT DUE CHECKED DATE PATE REMITTED AMOUNT I 43 FEE CZ LESS PRORATION II C) PLUS t /A PENALTY EOTHER F OTHER 19: t Received by Date Receipt No. Permit No. Issua ce Date Mailed ... Delivered APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES -.1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201