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ApplicationsWill BeProcessedWhen Submitted Properly Completed.Be SureToSign TheApplication. <br /> L 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 1455 Gillis Rd City/Town Stockton _ <br /> " Owner's Name Camera Brothers Farms Phone 464-1727 <br /> Address 1455 Gillis Rd City Stockton <br /> Contractor's Name Clark Well & Equipment License#371560 Business Phone 462-5597 <br /> v Contractors 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 M RECONDITION❑ DESTRUCTION❑ t� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 13 <br /> 6. REPLACEMENT❑ existin� Ag well-old permit ; 08098 <br /> DISTANCE TO NEAREST: Septic Tank ewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> r Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL i4N <br /> 11 INDUSTRIAL EI CABLE TOOL Dia. of Well Excavation <br /> ` ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 14" <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing . .250 <br /> M IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal NA <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information I <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <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 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 hIdn atr'rnIri .cin ignature certifies the following:"I certify that in the performance of the work forwhich this <br /> � per it i iss d, s II mpl per o s subject o workman's compensation laws of California." <br /> I I to out tion io rou g d a final inepectio <br /> Iy� `�/( @ <br /> Signed X Title: t/ —CC N RIC C Date: <br /> .. (Dr lot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By �- <br /> Additional Comments: <br /> Phase 11 Grout Inspection ase III Final Inspection Ar <br /> V Inspection By n Date Inspection By T Date 3-1S Z. <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 K Received By January 31 ❑ July 1 6 Received By July 31 <br /> REMIT <br /> rBASE EXPLANATION BILLING REMITTANCE $ <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> b. PRORATION _ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> Shia <br /> OTHER <br /> I.. Received by Date Receipt No pe,m,t No. Issue ce Datd Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bo.2009 STOCKTON,CA 9S201 <br />