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Applications Will Be Processed When Submitted Property Completed.Be Sure To Sign The Appi ca <br /> APPLICATION <br /> FfFrolal OFFICE USE: {For Non-Transfeiabfe,Revocabb;Suspendable} PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY _ x•r,.r �. •,-:�,, t <br /> (COMPLETE IN TRIPLICATE} <br /> all the WO <br /> Application is tie rebymade tothe San JoaquinLocal Health District <br /> i a dper rules and reguajations oftthe San Joaquinrk lLocriHealdth Dist.This rict. <br /> plicatian Is <br /> made in compliance with San Joaquin County Ordinance N City/Town <br /> Stockto <br /> •i 02 4 Childress <br /> Exact Site'Address Phone_IL=-"kQ9 <br /> Owner's Name A�X221 IUIaXOn ,.: City <br /> Stockton,•r Ca' 212 <br /> 102 0 Childress 1 60 Business Phone'+ 4 <br /> Address — -,r N A <br /> Contractor's Name Clark We11� & 'E til y tit; ' License# <br /> • � �•+..: . Emergency Phone'• ""Contractor's Address 202 E Charter Way No <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes STRUCTION❑ <br /> TYPE OF WORK{CHECK}: <br /> NEW WELLS DEEPEN❑ PRECONDITION V! <br /> ❑ - WELL ABANDONMENT 13 OTHER 13 PUMP-INSTALLATION C3PUMP REPAIR <br /> WELL CHLORINATION e <br /> REPLACEMENT❑ 74 Sewer Lines 80 r Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank ---- Other <br /> Cesspool/Seepage Pit <br /> Sewage Disposal Field 10, Public Domestic We <br /> Property Line Privatell <br /> Domestic Well f <br /> TYPE OF WELL Q $" <br /> INTENDED USE Dia,Of Well Excavation— 6 gll <br /> [I INDUSTRIAL ❑ CABLE TOOL <br /> [3 DRILLED Dia.of Well Casing 2 a t 9• <br /> ® DOMESTIC/PRIVATE Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC 13 DRIVEN <br /> ❑ GRAVEL PACK Depth of Grout Seal— cenment Grout ! <br /> ❑ IRRIGATION [� TARY a TyP Grout <br /> [IRO <br /> { <br /> CATHODIC PROTECTION informal on r.... rj <br /> Y- -�--_^ - - �❑OTHER <br /> ❑ DISPO5AL Surface Seat Installed By: i IL <br /> I <br /> ❑ GEOPHYSICAL <br /> Contractor „ H.P. <br /> PUMP INSTALLATION: Co <br /> Type Of Pump <br /> i ❑ State-work Done <br /> 'JMP <br /> REPLACEMENT-0 State Work Done "T�" "'•r` Approximate.. ` <br /> Well Diameter• - c. r - <br /> DESTRUCTION OF WELL: ¢ <br /> { Describe Material and Procedure <br /> 2 I� r .t # ,� <br /> I hereby.certify that I have prepared this application and that the work willHe.0 qi in.t corda5i'ellwith San Joagsin CoLnty - <br /> ordinances,state laws, and rules and regulations of the�nin ,Iuertify,th4t itithej6erfoirnanceoitheworkforwhic{,Iii ohis.olarmit <br /> Home owner or licensed agent's signature ce uoh manneries the asto b,rh4's'ub-jdct�'to workman's cornpensa4ion laws o <br /> Is is e , I shall not toy any pe V i certify that in the performance o1 the work fo>iwh1lo`f'this <br /> Co tr or's hiring r su -contractin slgilature certifies the following:' Y s ` <br /> per it s issued, I hall mpley er s subj tato workman's compensation laws of California." t <br /> I. fOr a Gro t 1 ti i .gr Ing and a fYnalF;insalection. + :,; 'Aad $� <br /> ` <br /> as Clark We11, Date: 5. <br /> Signed X' (D; w Plot Plan on Reverse Side) t }} <br /> } FOR DEPARTMENT USE ONLY _ + <br /> D to 1 <br /> PHASE 6 <br /> Application Accepted By _ <br /> Ad<konal comments:� � ..;.. --M.M.-- -- �-Phase III Final Inspection� ' <br /> _Phase-Ii Gro/ut.inspection e <br /> Date Inspection B� <br /> Inspection B ' <br /> ._� Janecaived By January 31 ❑July t& eceived 8Y July 31 <br /> REMIT <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT [3 PER S1TE ❑ EACH $ AMOUNT DUE CHECKED <br /> BILLING i REMITTANCE -REMITTED. AMOUNT <br /> BASE EXPLANATION DATE DATE <br /> i { <br /> .... `.Y` <br /> FEEN. <br /> LESS r- ` <br /> PRORATION <br /> i <br /> PLUS' <br /> PENALTY I <br /> OTHER ; <br /> i <br /> OTHER I <br /> S an RCB Mailed Delilered _ <br /> ' y permit No. Issuance Date <br /> Date Receipt Nd. STOCKTON,CA 96201 <br /> _ Received by �• 601 E.HAZELTON AVE.P.O.a°�2008 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />