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ApplicationsWill Be ProcessedWhen Submitted Property Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) / <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the 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 Add ress1_6_77��,___NOmL City/Town ,athro <br /> Owner's Name _ _ a 1 ("moi Phone 858-2511 <br /> � <br /> Address16777 S. Howl and — �U <br /> City T. <br /> Contractor's Name Clark P l l &_-Equip. License 9371560 Business Phone 46 <br /> Contractor's Address 2.0- 4 E_ Emergency Phone NA <br /> Is Certificate of Workman's Compensation Insurance on Fife With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL@ DEEPEN 17 RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Test Hole— Sewer Li sen field 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 ❑ CABLE TOOL Dia. of Well Excavation 6" <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing I12� <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing Yl <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout eal 1� <br /> ❑ CATHODIC PROTECTION 151 ROTARY Type of Grout •�� <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 0 GEOPHYSICAL Surface Seal Installed By: � <br /> PUMP INSTALLATION: Contractor _J <br /> Type of Pump H.P. _ ! <br /> PUMP REPLACEMENT: ❑ State Work Done LA <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 611 <br /> Approximate Depth ` 500' <br /> D scribe Material a9d rocedure 1 <br /> 4 <br /> I hereby certify that I have prepareR this application and that the work will be done in acc"'6rdance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed is signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, I shall not ploy a o such manner as to become subject to workman's compensation laws of California." <br /> Cantraclor's hiring or -cont ti sign ture certifies the following:"I certify that in the performance of the work for which this <br /> permit 's i Lied s I e pl y s S bjec workman's compensation laws of California." <br /> I r r ut I on ri r gr nd a final inspection. <br /> Signed X Title: VP--Clark Well ' <br /> Date: Au 2 �1_ 8� <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �� C/ 7 <br /> Application Accepted By _ Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By l-CXInspection By Dated <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER S17E ❑ EACH ❑ Jarivary 1 &Received By January 31 ❑ July Y &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE � � �-"� �� AMOUNT <br /> �J O <br /> d <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 3� a(0 <br /> Received by Date Receipt No. Permit No. Issuance ale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />