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~Applications Will Be Processed When Submitted Properly Completed. Be SureToSign ineApplicuaun. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) / <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described"This application Is <br /> made in com with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Addr s o ; mile East off' 1-5 City/Town French Cam <br /> Phone X06 54 <br /> Owner's Name -nS City Maider6 <br /> Address 9-7— <br /> Contractor's <br /> 7 J <br /> Lll ITl n-� License #3_T1,5bo Business Phone w , <br /> Contractor's Name �Z2x'k�I -_ —�—� NA <br /> Emergency Phone <br /> Contractor's Address _2D2_4__F_.—Cha-r' No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL Ed DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR i <br /> REPLACEMENT❑ in open field <br /> Pit Privy > <br /> DISTANCE TO NEAREST: Septic Tank ewer Lines ;. <br /> Sewage Disposal Field Cesspool/Seepage Pit Other e <br /> Property Line Private Domestic Weil Public Domestic Well <br /> INTENDED USE TYPE OF WELL 22„ <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 12 40, <br /> ❑ DOMESTIC/PRIVATE 1:1 DRILLED Dia, of Well Casing . 188 <br /> Q DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing a 1 lin <br /> ❑ IRRIGATION 5d GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION 0 ROTARY <br /> Type of Grout —Sack mix <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> lI hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> f y , <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 employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or s ntracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issu 1 sh plo per n subje to workman's compensation laws of California." <br /> I wil f o I p rio r g a d a final inspection. <br /> Title:VP-Clark Well Dare: Sept 791981 <br /> Signed X <br /> I (Draw Plot Plan on Reverse Side) <br /> I FOR DEPARTMENT USE ONLY �j <br /> PHASE I }J Date `_)5 �1 <br /> Application Accepted By <br /> Additional Comments: <br /> P�s 11 Grout Inspection pPhase Ill Final inspection <br /> Date—J4 —j '� Inspection By Date <br /> Inspection By ---r-�� <br /> Fee is Due: ED ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Ju1y i &ReceivedREMIT <br /> uIy 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> O <br /> FEE <br /> LESS <br /> f PRORATION <br /> tpp PLUS <br /> F PENALTY <br /> Ilr{ OTHER <br /> Ikff OTHER GL" <br /> Is uanc ate Mailed Delivered <br /> CA 95 <br /> Received by <br /> Date Receipt No Permit No. <br /> L 1601 E.HAZELTON AVE.,P.O.Box 2009. STOCKTON, <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ` <br />