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ppucationsWill Be Processed When Submitted"Properly Completed. Be Sure To Sign.The+Applie <br /> "' <br /> FOR OFFICE USE: _ APPLICATION' <br /> (For Non-Transferable, Revocable,Susperidable) +� <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetothe San Joaquin Local Health Districtfora permitto construct and/or install thework herein described.This application is X <br /> made in compliance with San Joaquin County Ordinance No. 1662 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address S . Hi' hwa 04 <br /> � � — City/Town Stockton <br /> owner's Name Bill Rackleyi Trucking Tncor orated <br /> Address 3755 Munford Ave Phone 466-4.521 <br /> i c;ty Stockton <br /> Contractor's Name Clark Well & Equip. <br /> Contractor's Address 2024 E. Charter License# 76 Business Phone 4.62-5597 <br /> Wa . Emergency Phone RAIs Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL® DEEPEN E] RECONDITION <br /> W <br /> WELL CHLORINATION C1 WELL ABANDONMENT 11RECONDITION❑ DESTRUCTION❑LLATION ❑ PUMP REPAIR❑ Lo <br /> I DONMENT OTHER 13PUMP INSTA <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: well in field, no septic , it will be installed later UJ <br /> Septic Tank <br /> Sewer Lines Pit Privy <br /> } Sewage Disposal Field Cesspool/Seepage Pit <br /> i Property Line 11 0=Private Domestic Well t 100 Other <br /> r Public Domestic Well <br /> INTENDED USE TYPE OF WELL _ <br /> ❑ INDUSTRIAL ❑ CABLE'TOOL '- <br /> DOMESTIC/PRI17ATE Dia. of Well Excavation_ 10 5 gn <br /> ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC 11 DRIVEN <br /> 6 8 rr + <br /> ❑ IRRIGATIONj Gauge of Casing <br />' ❑ GRAVEL PACK _ Depth of Grout Seal <br /> 11 CATHODIC PROTECTION M"ROTARY <br /> ❑ DISPOSAL ❑ OTHER T � Type of GroutGEOPHYSICAL <br /> p <br /> 11 GEOPHYSICAL Other Information <br /> PUMP INSTALLATION: S , Surface Seal Installed By: <br /> Contractor towell 1 <br /> Type of Pump H P p <br /> PUMP REPLACEMENT: ❑ State Work Done •�Y <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 /> Home owner or licensed agent's signature certifies the 1 lowing:"I certify that in the performance of the work for which this permit <br /> is issued, I shall not employ any person in such mann as to become subject to workman's compensation laws of California," <br /> Contractor's hiring orsub-contracting signature certifies <br /> permit is issued, I the following:"I certify that in the performance of the work for which this <br /> sh y er ons su ject to workman's compensation laws of California." <br /> I wit I or Gr 1 io r to rou 'ng and a final inspection. <br /> Signed X <br /> Title.- V.P. Clark Well <br /> (Draw Plot Plan on Reverse Side) Date: Noy. 2 0; 1979 <br /> PHASE FOR DEPARTMENT USE ONLY f' <br /> Application Accepted By I <br /> Additional Comments: Date / Z <br /> P <br /> Phase 11 Grout Inspection <br /> Inspection ByPhas I al Inspection <br /> Date <br /> W\Z-A� <br /> Inspection By ' Date �/ —� <br /> Fee Is Due: 13 ANNUALLY ❑ PER UNIT ❑ PER SITE <br /> ❑ EACH ❑ January 1 &Received By January 31fi <br /> ❑ July 1 &Received By 31 <br /> BASE EXPLANATION - BiLLING REMITTANCE $ REMIT <br /> '-} DATE DATEREMITTED AMOUNT DUE CHEC <br /> FEE J, 3 SMO <br /> LESS F <br /> PRORATION .� 1 <br /> PLUS V <br /> PENALTY <br /> OTHER <br /> OTHER <br /> q Received by Date_ Receipt No. <br /> i, Permit No. Iss nce Date Mailed <br /> AApLICANT—RETlJAN ALL COPIES TO: ENVIRONMENTAL HEALTH HERMIT/SERVICES, delivered <br /> L _ 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON.CA 952M 1_ <br />