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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR,OFFIdt USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL (/ <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE — pfw wIITER QUALITY r 01,3 3 30 -3 <br /> Application is hereby made to the San Joaquin Local Health Qist Ict fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with n Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Heal District. <br /> Exact Site Address M�he at Briggs City/Town �1 C. <br /> Owner's Name -•Merl.in kind uist` Phone' <br /> Address 26 ,.Country Club our x.^ City Stockton, 04 <br /> Contractor's Name Clark -Well & E6UilDment . License# 71560 Business Phone 462- <br /> Contractor's Address 202 E charter Way `15597— <br /> Emergency Phone N A <br /> Is Certificateof Workman's Compensation Insurance on File With SJLHD? Yes x No <br /> TYPE OF WORK (CHECK):w"NEW WELLO DEEPEN'El' RECONDITION❑ DESTRUCTION❑ Q�) <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑.. PUMP INSTALLATION ❑ PUMP REPAIR❑ r <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 001 Sewer Lines 1001 Pit Privy <br /> Sewage Disposal Feld Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL € ; <br /> 11 INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation 10 5 ;8"! <br /> 0 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 5 811 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 2 i <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 50' d <br /> ❑ CATHODIC PROTECTION K] ROTARY Type of Grout Bentor�it'e <br /> ❑ DISPOSAL ❑ OTHER !Other Information _ <br /> ❑ GEOPHYSICAL <br /> .,� .,,�...,,,,„,fSurface_Seal_lnstaNed.,By:• <br /> PUMP INSTALLATION: <br /> Type of Pump H.P. r <br /> PUMP REPLACEMENT: ❑ State Work Done E, <br /> PUMP REPAIR: E State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure E <br /> T. i <br /> t 4 <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 regulatidhs-of'the San,'Joagain•:Lo al Health District. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work'forv¢hich 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-certilieslhe-following:.':.l-certify-that-in,the.per-formanc-e,of-tk�e•v�A for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." $' u <br /> I will call for a Grout-ins ion pr'i to groutina a final inspection. <br /> Signed )C l �t �` Tiile1 t `�-J aWner f3�' � � <br /> Coate: 3 0 April 8 <br /> k (Draw Plot Plan on Reverse Side} <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 �,�P E <br /> 1-3 <br /> Application Accepted By {~ 120 <br /> " Date <br /> Additional Comments: r—HaI4r s � <br /> P se Grout Inspection '? 4 Phase_III Final Inspection <br /> Inspection By Date Inspecti6n By;L e Dat <br /> r t ~ <br /> Fee IS DUe: ❑ ANNUALLY ❑ PER UNIT PER SITE <br /> ET-EACH, ❑ January 1&Re veb By January 31 'July i &Received By July 31 <br /> BILLING4,N'REMITTANCE t FIEMIT <br /> BASE EXPLANATION $ AMOUNT DUE CHECKED <br /> r DATE �"t `-.DATE �REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION ` <br /> PLUS <br /> PENALTY e <br /> OTHER — <br /> OTHER <br /> l0(0 914 " I <br /> Received by Date Receipt sua No. Fsermit No. sce Date .Mailed! Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />