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Applications Will B."rocessedWhen Submitted Propertyuomplerea. Cie zbure 1oalgn 1nee+ppiluaclurr. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin local Health District fora 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 2 63 E Mariposa City/TownStockton <br /> Owner's Name O n Orth nc Phone __9 <br /> Address -2. 463 F ari iposa City Stockton <br /> Contractor's Name Clark Well & Ec u-i-p License#371 60 Business Phone 462-5597 ) <br /> Contractor's Address X024 E. Lharte��. Emergency Phone NA <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No /^ <br /> TYPE OF WORK (CHECK): NEW WELLS DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ [J l <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ e—. <br /> DISTANCE TO NEAREST: Septic Tank 4 —7 4 Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Lina$? Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL / <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 10 5/ 8" <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing 6 5/811 - <br /> 0 DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing # 12 Steel <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 501L <br /> ❑ CATHODIC PROTECTION CR ROTARY Type of Grout Bentonite <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 emplo any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or -cont g 'gnature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issu , I all p erson subj t to workman's compensation laws of California." <br /> I or G t io r' gr and a final inspection. <br /> Signed X Title: VP-Clark Well Date: Qct 12 ,1981 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I © 8)1 <br /> Application Accepted By Date J <br /> Additional Comments: <br /> hase II Grout Inspection Phase III Final Inspection 1 p <br /> Inspection By Date rly Z�� / Inspection By�a � Date 11 -1 6_-z'1 <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEELESSoi <br /> j�?// <br /> ,JPRORATION !�-- C/pPIfJI�G <br /> PLUS <br /> PENALTY <br /> OTHER Cy I��I-V;7, <br /> OTHER <br /> Received by Date Receipt No. Permit No. issua ce 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 />