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ppucationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application, <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ``Y + ENVIRONMENTAL.HEALTH PERMIT PUMP&WELL <br /> Uv4 �j <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> 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 <br /> made in compliance with San Joaquin County Ordinance No. 18621and the rules and regulations of the San Joag,uin Lo al Health District. <br /> Exact Site Address 00 mm <br /> E. Hamer Lane City/Town titocrton <br /> Owner's Name Stockton Steel Phone 931-4751 <br /> Address City Stoekton <br /> Contractor's Name Clark p l —E4_uipment License#371560 Business Phone 462-559 <br /> Contractor's Address Emergency Phone- NA <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL IR DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> k WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> ' REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank +100• Sewer Lines Pit Privy <br /> Sewage Disposal Field + 11 Cesspool/Seepage Pit Other <br /> Property Line +100tPrivate Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation a <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 8 5/8n <br /> 13:DOMESTIC/PUBLIC El DRIVEN -of Casing _ #,_#2 Steel <br /> ❑ IRRIGATION El GRAVEL PACK Depth of Grout Seal 1 <br /> ❑ CATHODIC PROTECTION XI ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER 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 Approximate Depth <br /> 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 /> 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 hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issue to person subject to workman's compensation laws of California." <br /> f t wi c I r ti pri grouting and a final inspection. <br /> Signed X Title: VP—C 1:4rk Well Date: 19 May 1 <br /> (Draw Plot Plan on Reverse Side) <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI � <br /> Application Accepted By—. l u _ /.f 1-C�_. ` _ Date <br /> Additional Comments: <br /> Phasa II Grout Inspection r Phase II Final Inspection <br /> Inspection By Date J � j)_ <br /> Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT. ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE REMIT <br /> BASE EXPLANATION A <br /> l DATE DATE REMITTED MOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> I OTHER <br /> llll _ '• I <br /> .3 �� <br /> Received by Date Receipt No, _ r - Is uance Dae Mailed Delivered ' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES 1691 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> 1 <br />