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I _ <br /> FOR OFFICE.USE: APPLICATION <br /> { (For Non-Transferable, Revocable, Suspendable) <br /> Rcia <br /> WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaqu'sn Local Health District for a permit to construct and/or install the work herein described.This application is <br /> j 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�QDN Aratg Rd City/Town Stockton <br /> j Owner's Name Rick Arta Phone Work 931--1470 <br /> Address 6935 Village Green. City Stockton <br /> M Contractor's Name C l ark Well & Fq u imet License#_UI_5j60 Business Phone. 462-5597 <br /> Contractor's Address Emergency Phone N <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ ` may <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 5 Sewer Lines Pit Privy t <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—_ lo 5f8'1 <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 1 2 Steel <br /> j - ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 50, <br /> I ❑ CATHODIC PROTECTION Ek ROTARY Type of Grout Bentonite <br /> i <br /> C1 DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> FPUMP INSTALLATION: Contractor <br /> !. Type of Pump H.P. �\ <br /> PUMP REPLACEMENT: ❑ State Work Done C° <br /> F <br /> PUMP REPAIR: ❑ State Work DoneDESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> • <br /> i 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:"I certify that in the performance of the work forwhich this permit NNN <br /> i employ is issued, I shalt not <br /> I p y an y person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> S permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I w all for a Grout Inspection prior to grouting and a final Inspection. <br /> Signed X Title: f Date: <br /> (Draw Plot Plan on Reverse Side) <br /> 'FOR DEPARTMENT USE ONLY <br /> F1 PHASE I G j <br /> Application Accepted B )6) ' Date o21 <br /> Additional Comments: t <br /> fa ll Grpt Inspection 7 y Phase III Final Inspection <br /> Inspection By " '+ oate— � � Inspection By 10V/71 Date <br /> f Fee Is Due: 13 ANNUALLY E-3PERUNIT 1:1 PER SITE El EACH El January 1 &Received By January 31 El July 1 & Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> I pATE DATE REMITTED AMOUNT <br /> { — <br /> FEE <br /> LESS <br /> 1 PRORAT3ON <br /> PLUS y� <br /> R PENALTY <br /> i <br /> OTHER <br /> f i`iV <br /> OTHER G'^ <br /> Received by nate Receipt No. Permit No I suanc ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />