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 <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <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 compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 17b1 Howland Site 6 City/Town _Lathro <br /> Owner's Name �C_C_l _ n } h2m1 C 1 O. Phone 858--2 1�1 <br /> Address 17631 S . Howland City Lathrop �— <br /> Contractor's Name Clark Well & E U15597 <br /> License# 371560 Business Phone 62— <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 WELL® DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ near GypOnd <br /> DISTANCE TO NEAREST: Septic Tank ewer 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 /> IMINDUSTRIAL Monitor ❑ CABLE TOOL Dia. of Well Excavation A�I 2tt 8�r <br /> ® DOMESTIC/PRIVATE standardsstandards[] LV.DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing # 12 <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 138' <br /> ❑ CATHODIC PROTECTION ® ROTARY Type of Grout 9 Sack rnix <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 i <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 forwhich 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 -contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued I all emp s subi to workman's compensation laws of California." <br /> 1 w' I or ou In ion i g Ing a a final inspection. <br /> Signed Title: VP- Clark Well & e ui Date: May 20 ,11a-0 <br /> (Draw Plot Plan on Reverse Side) <br /> Ii FOR DEPARTMENT USE ONLY <br /> PHASE I To <br /> Application Accepted By Date <br /> Additional Comments: <br /> Ph s Grout Inspection Phase 111 Final Inspection / <br /> Inspection By ate L Q Inspection By ate <br /> i <br /> Fee Is Due: []'ANNUALLY C1 PER UNIT [J PER SITE E] EACH El January 1 &Received 8y J nuary 31 July i &Receive Bqjy 1 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> t yy�, 'L.,`� DATE DATE REMITTED rr��,.. AMOUNT <br /> I FEE `rS 4 S $ 43 i3 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER + <br /> 1 <br /> OTHER <br /> Received by Date Receipt No, Permit No. I Issuancdi 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 />