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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> RFOROFFIGE USE: APPLICATION <br /> (Far Non-Transferable, Revocable,°Suspendable) pIJ/Vlp&WELL <br /> f <br /> w ! <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. 1$62 and the rules and regulations of the"San Joaquin Local Health District, <br /> Exact Site Address 6011 West- Lane" { �" `; <br /> City/Town` Stockton <br /> Owner's Name jester8, Club ','*] � <br /> Address k} Ptior49 <br /> Contractor's Name r City <br /> tE+Y, ��t..,. m�„u� License# - <br /> Contractor's Address Man <br /> Business Phone <br /> tl.; r 3 Emergency"Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑'- ..DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT T `^' <br /> } }� OTHER ❑ PUMP INSTALLATION ❑ <br /> REPLACEPUMP REPAIR❑ <br /> MENT❑ " � rte„ <br /> DISTANCE TO NEAREST: = Septic:Tank Sewer Lines <br /> Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit <br /> Other <br /> ,. Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE j TYPE OF WELL <br /> ❑ INDUSTRIAL- ❑ CABLE TOOL <br /> ❑ DOMESTIC/PRIVATE ❑t" Dia. of Well Excavation <br /> DRILLED <br /> ❑ DOMESTIC/PUBLIC C1 DRIVEN Dia. of Well Casing <br /> ❑ IRRIGATION Gauge of Casing <br /> ❑ GRAVEL PACK Depth-of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY <br /> Type of Grout _ <br /> 0 DISPOSAL I ❑ OTHER ��"" "�"'••Ottier Information � �¢ <br /> 13 GEOPHYSICAL t Surface Seal Installed By! I <br /> PUMP INSTALLATION: Contractor <br /> 't ' Type of Pump 4 H,P, ! <br /> PUMP REPLACEMENT: h ❑ State Work"Done <br /> PUMP REPAIR: `` E <br /> 1:1 State Work Dane A. <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> +t r Describe Material and Procedure <br /> I hereby certify that I have'prepared this application and that the work will be done in accordance with San7whichthis <br /> ordinances, state laws, and.rules and regulations of the San Joaquin Local Health District. I <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work foris issued, I shall not employ any person in such manner as to become subject to workman's compensation laContractor's-hiring orsub-contracting signature certifies the following:"I certifythat in the performance of the woorwhich this <br /> permit is issued, ! shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. + <br /> 3 7 <br /> Signed X •. l Title: � 1 <br /> Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted,By € <br /> Additional Commen Date.Lir-216_X-3 <br /> IPhase If Grout Inspection T " ` "" - -�- <br /> P se Final Inspection <br /> Inspection By - Date Inspection B <br /> p Y �✓Date `r <br /> Fee Is Due: ❑ ANNUALLY ❑,PER UNIT PER SITE ❑ EACH <br /> ❑ January1-8,Received By January 31 [] July 1-R Received By July 31 <br /> �DASE' EXPLANATION BILLING REMITTANCE _ $ F11)N <br /> 'REMIT <br /> I DATE DATE REMITTED CHECKED <br /> FEE ' AMOUNT <br /> LESS I'PRORATION <br /> PLUS <br /> PENALTY <br /> s <br /> w <br /> OTHER <br /> OTHER <br /> LD <br /> Received'by Date Receipt No ,Y a permit N. <br /> Issu ce Date Mailed Delivered. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E,HAZELTON AVE.,P.O.Box 2009 y STOCKTON,CA 95201 <br />