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AP pllcr�Rons Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE-U$E: APPLICATION (For Non-Translerabie, Revocable, Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District 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 the rules and regulations of the San Joaquin Local Health District. t Exact Site Address 150 North Sinclair City/Town Stockton r Owner's Name The Marley_C.00ling Tower Company Phone 465-3451 c+� {{{ Address <150`--NorthSinclair" _ City Stockton Contractor's Name Clark Wdl1 '&'Eu1' ment License# 71� 560 --Business Phone 462-5597 Contractors Address 202 E. Charter Way Emergency Phone NA ,J Is Certificate of Workman's Compensation Insurance on File With SJLHO? Yes No _ TYPE OF WORK (CHECK): NEW WELL® DEEPEN 11RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION 13 WELL ABANDONMENT❑ OTHER 13 PUMP INSTALLATION 11 PUMP REPAIR❑ r REPLACEMENT❑ tl`f DISTANCE TO NEAREST: Septic Tank 'F ?5' Sewer Lines +751 Pit,Privy Sewage Disposal Field Cesspool/Seepage Pit _ Other } Property Line t]'0 Private Domestic Well +100' Public Domestic Well - IEEE . INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation 10 8r' W DOMESTIC/PRIVATE 113 DRILLED Dia. of Well Casing 6 5 8" ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 12 Steel Pipe K ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 01 O ❑ CATHODIC PROTECTION ® ROTARY Type of Grout z ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: Clark 04 r, PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done 1 PUMP REPAIR: ❑ State Work Done -- DESTRUCTION OF WELL: • Well Diameter +' Approximate Depth _._ A. 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 San Joaquin Local Health District. + Homeowner orlicensed agent's signature certifiesihe following:"I certifythat inthe performance of the work forwhichthis permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contracioes hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for wh ich this permit is issued, I shall employ persons subject to workman's compensation laws of California." 1 11IdI call for as Grout Inspection prior to grouting and a final inspection. -7 _"�Ir V --*+ww�vu+.Y—t✓ VIT. ZJY�OQ. Date: I $C� ! Signed X Title: . (Draw Plat Plan on Reverse Side) i FOR DEPARTMENT USE ONLY PHASE 1 .? Application Accepted By Date 0 Additional Comments: has I Grout Inspection 1 7� Pira II Final Inspection j/�, ((1{' Inspection By LU . Data rill V Inspection By e,�le�C.r'�,iC E`lHJ`® o _._ Fee Is Due: 1] ANNUALLY ❑ PER UNIT ❑ PER SITE ❑-EACH ❑ January 1 a Receive By anuary Q July 1 a Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNTOUE CHECKED DATE GATE REMITTED AMOUNT FEE �. 3 -4 L(-3 LESS PRORATION PLUS Ilfr PENALTY OTHER r - OTHER d53t5 L-4-I 'lI`$� Receivetl by Dale Recept No. Permit NO. Mailed Delivered 1 APPLICANT=RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES x601 E.HAZCLT0N AYE.,P.C.Boa 2005 STOCKTON,CA 85401