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Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTheAppncatton. <br /> APPLICATION / <br /> FOR OFFICE USE: �J <br /> (For Nan-Transierable, Revocable, Suspendable) <br /> I PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> 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 1455 Gillis Rd 6 City/Town Stockton <br /> Owner's Name Camera Brothers Farms Phone 1(6 -1 2 <br /> Address 1455 Gillis RdCity Stockton <br /> I <br /> I Contractor's Name Clark Well & E ul ment License# 371560 Business Phone <br /> 462" <br /> NA <br /> Contractor's Address 2024 E• Charter Way Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> ( TYPE OF WORK (CHECK): NEW WELL El DEEPEN M RECONDITION❑ DESTRUCTION❑ (� . <br /> ` WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR ) <br /> f REPLACEMENT❑ existin� Ag well-old permit # 08098 <br /> M DISTANCE TO NEAREST: Septic Tank ewer,Lines Pit Privy <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 91 CABLE TOOL EDia, of Well Excavation 1n <br /> w_ ❑ DOMESTIC/PRIVATE 13DRILLED Dia. of Well Casing <br /> 1411.250 411 <br /> ElDOMESTIC/PUBLIC 11 DRIVEN Gauge of Casing •2 \ <br /> ® IRRIGATION ❑ GRAVEL PACK 11 Depth of Grout Seal NA <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER li Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL:: Well Diameter .d Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application arid 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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, i shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hirin - in ignature certifies.the following:"I certify that in the performance of the work for which this <br /> per it i iss d, s II mp per o s subject o workman's compensation laws of California." <br /> I i io out tion io rou g d a final inspectio <br /> Signed X 5 Title: p c`� � Date: Z e <br /> (Dr lot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> i <br /> PHASE I -' -C� ` �- <br /> Application Accepted By "`"'"""'"���-���"'""" Date <br /> ` Additional Comments: <br /> Phase II Grout Inspection ase III Final Inspection <br /> Date Inspection By - ����-� Date <br /> Inspection By - - <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UWT ❑ PER SITE ::❑ EACH ❑ January 1 &Received By January 31 ❑ July i &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT RUE CHECKED <br /> BASE EXPLANATION <br /> k DATE DATE REMITTED AMOUNT <br /> I FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> i <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. ermit No Issua ce Da1Z Mai$ed Delivered <br /> APPLICANT—RETURN ALL COPIES T0: - ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />