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Applications Will Be Processea wnen Suornmeo Yropeny I.ompleteu. tae sure t u atgn 1 ne APPncauun. FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable, Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT L (COMPLETE IN TRIPLICATE) WATER QUALITY 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 made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San JoeI Lo al Health District. Lj Exact Site Address 1455 Gillis Rd City/Town Inockton I` Owner's Name Camera Brothers Farms Phone 464-1727 Address 1455 Gillis Rd city Oc On Contractors Name Clark Well & Equipment License If 371560 Business Phone 2-5597 y, Contractor's Address 2024 E. Charter Way Emergency Phone NA ; Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_ No Cz TYPE OF WORK (CHECK): NEW WELLXX DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ (y Ir WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ Ag Well in Orchard DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL - ❑ INDUSTRIAL ISKCABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing . 250 XXIRRIGATION ❑ GRAVEL PACK Depth of Grout Seal NA ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout •e ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor V�1 6. Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth V Describe Material and Procedure I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County L ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Ho wrier rlicensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit is' sued, I s II not employ any rson in such manner as to become subject to workman's compensation laws of California." 7� ontractoY hiring or sub-co actin signature certifies the following:"i certify that in the performance of the work for which this see permit ' ssued, I shall em oy p ns subject to workman's compensation laws of California" I I call for a Grout In do p or to grouting and a final inspection. Signed Title: Owner Date:Sept. 18 ,1980 V (Draw t Plan on Reverse Side) IF FOR DEPARTMENT USE ONLY PHASE I �� ML"., n , _ _ ©U `�^(� �-�-��,,� '"�Lti -*�`s-0'� ` Date Application Accepted ByL Additional Comments: > -- Phase II Grout Inspection has I Final Inspection L Inspection By-1i1(-a-�{� -- Date Inspection By - Date d=� Fee Is Due: ❑ ANNUALLY t(❑'PEER-UNIT ❑ PER SITE ❑ EACH ❑ January 1 &R etl By January 31 ❑ July 1 &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE E AMOUNT DUE CHECKED See BASE DATE REMITTED AMOUNT FEE lee LESS PRORATION - PLUS PENALTY — — OTHER OTHER Received Dy Date Receip[No. Permit No, ante ate Mailed Delivered Vrm APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA ELTON AVE.,P.O.90.Z00S STOCKTON,CA e5Z&