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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE; APPLICATION (For Non-Transferable,Revocable,`Suspendable) PUAAP&WELL r ENVIRONMENTAL HEALTH'PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District for a.permitto construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No. 11862 and the rules and regulations•{of the San Joaquin Local Health District. Exact Site Address LF1N. + a ' " "� ' City/Town "'"Linden f Owner's Name #3,' be S Address 01tFN-„ Wall -n<: Phone 88 �}sr: } s„ :, •. > city Linden . Contractor's Name Clark Well &: E ui menu- r Ltcerise# 60 Business Phone ”:462- , ;. f Contractor's Address 202 6 E:. Charter Way,, }Emergency Phone=- NA."-#? E's?r > • ; Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): ..NEW WELL® DEEPEN ❑ RECONDITION❑'__ " DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ r 01 REPLACEMENT❑ . : .; } .� DISTANCE TO NEAREST: Septic Tank -I' 0 t p sewer Lines Pit Privy Sewage Disposal Fieid R=_ 0' Cesspool/Seepage Pit Other Property Line_±1_50'Private Domestic Well 20' _ Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation. 10 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing• E 811 ❑ DOMESTIC/PUBLIC - I ❑ DRIVENGauge of Casing' " .125 Steel _ ❑ IRRIGATION _ .i ❑ GRAVEL PACK. ..., Depth of Grout Seal 501 ti ❑ CATHODIC PROTECTION # ❑ ROTARY Type of Grout?� C. 2 -� ❑ DISPOSAL, r ❑ OTHER j' , Other Information ❑ GEOPHYSICAL } `Surface Seal Installed By: i✓ L�El . PUMP INSTALLATION: Contractor 1 �}uvVt-wee Type of Pump '" H.P. 1 PUMP REPLACEMENT: ❑ State Work Done 1 ) PUMP REPAIR: ❑ State Work Done f DESTRUCTION OF WELL: I Well Diameter Approximate Depth Describe Material and Procedure I i �- 4 �4 3 5..,_ hereby certify that I have prepared this applic7t on and that the work will be done_in accordance with San Joaquin County ordinances, state.laws, and rules and regulations of the San Joaquin Local Health District. ?7 Homeowner or licensed agent's signature certifies the following:','I certify that in the performanceof the work forwhich this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:"I certify.that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensation laws of California." I w al f r a Grout s on ri r t ;,..a finai a p graufing and a l inspection.ry i Signed X - Title: a O ,Date: (Draw Plot Plan on Reverse Side) FOR DEPARTM NT USE ONLY {{11 PHASE 1 V,_ v p Application Accepted By - Date Additional Comments: Phase II Grout Inspection Phos III Final Inspection Inspection By � �-�.+z Date S �l T Inspec4ion By Date Fee IS"Dile: ❑"ANNUA_LL'Y07PER UNIT" ❑ PER SITE "r'"-""❑`EACH '❑Janua" 1 &Recdi4ed'B Januar"31""" 1 rY Y Y ❑'Ju"iy 1'&Received"By July 31 ' - �, BtL•LING tk REMITT.ANCE'� _ $ REMIT BASEEXPLANATIONDATE " DQTE AMOUNT DUE CHECKED REMITTED AMOUNT FEE sJ LESS ' PRORATION PLUS *' PENALTY OTHER, r • OTHER r y Received by- Date Receipt No,'. - rmit No.. _Issu ce Da a Mailed Delivered APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.B.Box 2009 STOCKTON,CA 95201 ,