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r <br /> 1 <br /> Applicallonn will tar Processed Whnn Submitted Property Completed. Be Sure To Sign The Application. <br /> Fc,ix o>rrF'7 use:I APPLICATION i <br /> (For Non-Tranefe rabic,Revocable,Suspendable) t^1ii11I' e VYELL <br /> l ENVIRONMENTAL Fig ",TN PERMIT J <br /> -- WATER QUALITY 1 <br /> (COMPLETE IN TRIPLICATE) I <br /> ApalrLation is riEtreby rn.nd SU tr •��^ "�'.;;n I-ry�;ri!tiralth'J�StTICf(Or a )(,(mit to Cbn31r41Ct nd/ar ln.SlTiil lhC work herein described This appirCanO/>s r3 <br /> made In Compliance Yriih San n;'W:y ow,nanCo No. 1362 ani)She rules and feQL IaL'on6 of the SAn Joaquin Local Health DIAblet, y i <br /> : Exact sitCnddress 2.024 East rh�rtB= �ay. Cit /Town _S.tockton <br /> r Owners Name -_ Robert Z:. la—,k _ _. . Phone ___ 462-5597 . <br /> _2000Last Char tcr ,Way city_._ _•,s-Stockton <br /> Crtlr'ctrrr?;NameClark Well 8: Is'c;ip CD._ Inc , Lic nro n76601, ©ueiness Phone.. <br /> C:JrtrRGlQrg lddress <br /> 2024 E Charter WEly. . „. -. , N rmergoncy Pilot tl <br /> i5 CertrllCalo pl VJAryman's rr7rnls^n,Ei:�r;n Ir,a<._irance on File With SJLHD'7 Yos , X ._:-. No r <br /> �- <br /> TYPE OF WORK (CHECK) NEvr VTI-L0 DEEPEN 0 RECONDITIONS DESTF;UCTIONC3� � I <br /> WELL taHLORINAT1CiN❑ VIFLI. ATIA dDONMENT 13 OTHER ❑ PUMP NSTALLATION❑ PUMt'i;EPAIR© <br /> REPLACEMENT G �0 <br /> DISTANCE TO NEAREST' Spptic Tzni Sowrr Linc9 .,/�0.. Pit Privy <br /> y�/ <br /> ,ri�;w9;•, C'.P:�•:^.I 1=irrld � •{-.-.... Ctl9dpoollS(1P. <br /> � p 40 Pit ,..../i'��ds.,Tv-- <br /> S° i'rOpr"y L�nr''7,� t.. Othpir <br /> P(IV, Dome <br /> stieWell_,�2eDv ubiic Domestic <br /> si <br /> A iNTENDEO USE ` TYPE OF WELL <br /> �fr <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia.of Well Excavation <br /> DOMESTICtPnIVATE © DRILLED Dia.of We Ii Casing <br /> ❑ DOMESTIC.'PUBLIC © DRIVEN Gauge ofCasing <br /> ❑ tnH'sGAT.lO?d ID GRAVEL PACK " Depth of Groul.soat <br /> R G CAT HODIC PROTECTION 0 ROTARY � Type of G out� �Benton! <br /> G OTHER Otho Int rmation J ' <br /> © OI�POSAL <br /> a ❑ GEOPHYSICAL Surface,S ni Installed By; <br /> °o <br /> PUMP INSTALLATION: ,tr.Ictor - <br /> Ptim <br /> "rI❑ Slate Work Oono <br /> PUMP REPLACEMENT: <br /> PUMP REPAIR: ❑ State Noris DJnv- <br /> OF-STRUCTION OF WELL: Nell Diamotar Approximate Depth <br /> r <br /> Describe Material and Procedure <br /> a +y� <br /> rL <br /> I hereby Certify that 1 hive o•^pared this application and that the work will be rlgne in accordance with San Jgagl,yn County � <br /> I <br /> ofdlnancCF, slat(r laws, and rues and regulations of rho San JoaQuirrLoeal ljeAlth DiSuict- • a 1 <br /> i Homeowner orlicenaodagent's signaturecertliivstlrefollowing:"Icertify the inthe performance oithev4orklorvQhichthis permit r� <br /> +t'-rey�llCld, I shalt not employ any prr�on in such manner as to become subj t W workman's compensation laws of California.' <br /> r <br /> Cont clots hiring or subcontracting signaturo certifies Sha following:"l cert ly lhAI in the pe <br /> of the work for which chis q , <br /> per i is issued, 1 I em Pcompensation laws of California.'* 1 <br /> 1 wil II for a G ut spec riot to uting and a Ilnal Intpeetior+ <br /> .+ <br /> cera•� Owner March 7, 19 F <br /> I i Signed X <br /> (Draw-Plot Plan on Reverse Sidc <br /> rt OR CEPARTMENT USE O LY <br /> •, <br /> �+ <br /> PRASE k <br /> LDatl;:3� <br /> Application Accepipd <br /> 4 Additional Comments:_.—.__. -. .._....__. -- Joe <br /> Phase 11 Grout Inspection Phase tri Fingl lftsiipn <br /> inspection B _-- Date Insp tion By�s,c�4�i ate <br /> . i Q July c 8 Retailed BY JviY 31 <br /> Fee Is Due: ❑ ANNUALLY © ren u 7 r>r:n s17 13 s ncH __C3 Ja ry d ricceWep By Janua 3i REMIT -- <br /> ' BILLING I nEMITTAN E 1 S AMOUNT DUE CMECKED <br /> 5. i 4ffw^51E <br /> EXPLANATION - DATE _^HATE i— REMITTED _ AMOUNT �., <br />