Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> ` (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL 1 <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE 1N TRIPLICATE) ie WATER QUALITY J <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 ?119 E. Mariposa Rd T1N-R7E city/Town Stockton <br /> Owner's Name Murphy Bros . Farms Phone 714-756-2081 <br /> Address P . O, BOX 517 City Sierra Madre <br /> Contractor's Name CLARK WELL & EQUIPMENT License# .76602 Business Phone 462--5597 <br /> Contractor's Address 2024 E. Charter Way Emergency Phone NA <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELLKI DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION © WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ NEW"AGRICULTURAL WELL IN OPEN FIELD <br /> DISTANCE TO NEAREST: Septic Tank .1 Sewer Lines 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 4ql 24rr <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 6" <br /> ❑ 'DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing . 250 <br /> 11-IRRIGATION ® GRAVEL PACK Depth of Grout Seal NONE <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout None <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: STOWELL V <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P, <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done t <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> F ! 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 /> Home owner 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I w' II f o Iction for to grouting and a final inspection. <br /> Signed X Title: _V.P. Clark Well & Equi -Date; OCT 18 , 197_ <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / <br /> Application Accepted By DatP/� <br /> Additional Comments: _ <br /> Phase I Grout Inspection al Inspection <br /> Inspection By Date Inspection ?eceived <br /> � Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 & y January 31 ❑ July 1 &Received 8y July 31 I <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE AMOUNTD <br /> FEE <br /> LESS <br /> PRORATION ' <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER l <br /> _ -7c1-11-77 I �/ l �G <br /> Received by- Date Receipt No. Permit No. Issuance Date Mailed Delivered. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES _ 1601 E.HAZELTON AVE.,P.O.Box 2049 STOCKTON,CA 95201 <br />` �- <br /> 1. _ . . - - _. rp <br />