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Applications Will Be Processed When Submitted Properly Completed. Be SureToSign TheApplication. ( =SCE USE: APPLICATION `y , (For Non-Transferable, Revocable, Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) - WATER QUALITY Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described"This application is made in compliance with Sari Joaquin County Ordinance No.1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address 2 60 Hall Avenue City/Town Stoctton Owner's Name Harley MurrayPhone 46 —21( 8 Address 2560 Hall Avenue City Stockton Contractor's Name Clark Well & Equipment License#_3 1 60 Business Phone �'b2-597 Contractor's Address 2024 E Charter Way Emergency Phone N A Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No L� TYPE OF WORK (CHECK):.. NEW WELL M DEEPEN ❑ RECONDITION❑ DE=STRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank , 100 t+ Sewer Lines 1001 + Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other i Property Line Private Domestic Well Public Domestic Well 1 INTENDED USE TYPE.O_ F WELL ❑ INDUSTRIAL >1071 ❑ CABLE TOOL Dia. of Well"Excavetion 1� Z DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DRIVEN _Gau a of Casing Err 13 DOMESTIC/PUBLIC 9 9 11 IRRIGATION ❑ GRAVEL PACK Y ` `Depth of Gr6ut Seal" 50 r ❑ CATHODIC PROTECTION ® ROTARY ` " Type of Grout Bentonite 13 DISPOSAL ❑ OTHER - Other Information 11GEOPHYSICAL RE. - 4.. f Surface Seal Installed BY: PUMP INSTALLATION: Contractor CD Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth 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 or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit is issued, l shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this per is issued, I shall employ persons subject to workman's compensation laws of California." ` r 1 w'I II for a G t In on p r 10 grouting and a final inspection. Signed X Title: S e C-Tre S Date: 1 7 Sep 80 (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I Dake 7 Application Accepted By. si Additional Comments: . Phase II Grout Inspection A s inal Inspection �C Inspection By Date U Inspection L' Date ii Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 ece ed By January 31 ❑ July 1 &Received By July 31 1 1 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE MITTED AMOUNT FEE 3 LESS PRORATION // 1 4E 1 n rs_ Mor♦�� PLUS !bl1G161 / PENALTY � _ is c nJvr�Cif 1-yJ� OTHER I I t ()n [ I k d a 4-�- 1 � 6e_ Y✓ '." OTHER ° i i Ctz-e„i{.n � rlvr uo1�/= 0 �38 Received by Date ReceiptNoPermit No. lissuan a Date Mailed Delivered e APPLICANT—RETURN ALL COPIES TO: _-ENVIRONMENTAL HEALTH PERMITISEAYICES 1fi01 E.HAZELTON AVE.,P.O.Bow 20119 570CKTON, A 95201