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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR-G FICE USE: APPLICATION l <br /> (For Non-Transferable,Revocable,Suspendable) 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 4724 Cherokee Rd/ City/Town Stockton <br /> Owner's Name AnIUE'1 La 'Stella Phone ! y <br /> Address same City <br /> Contractor's Name Moorman' S'.Water SyStl?MS; License#267696 _ Business Phone � <br /> i <br /> i' Contractor's Address 2120 Wilcox-Rd. "1 Emergency Phone ) <br /> G Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_ X No en n <br /> TYPE OF WORK (CHECK): NEW WELL El _ DEEPEN ❑' RECONDITION❑ DESTRUCTION❑ LL WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP.INSTALLATION-_�I;. PUMP REPAIR-13 Q} <br /> ' REPLACEMENT❑ <br /> t ti <br /> i <br /> DISTANCE TO NEAREST: Septic Tank Sewer 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 /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC'PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information 1 <br /> ❑ GEOPHYSICAL -a Surface Seal Installed By: ? <br /> PUMP INSTALLATION:; Contractor Moorman s Water Systems <br /> Type of Pump—_ SUbMerSible H.P, 1 <br /> PUMP REPLACEMENT: 151 State Work Done- rB <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 /> Home owner 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 hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. /- �J <br /> Signed X _ ���-s�-rcerJ Title: � --[�s��-�r_��t0 Date: <br /> ! (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _ <br /> Application Accepted y Date <br /> Additional Comments ' <br /> Phase 11 Gr�r y�nspection P se I Fi I Inspection <br /> Inspection By Date -+• Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January S &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING - REMITTANCE $ AMOUNT DUE CHECKED <br /> [� I DATE DATE REMITTED AMOUNT <br /> FEE tp <br /> I LESS i <br /> EPRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date - Receipt No. - F-• ,u Permit No. - Iss ante Dae Mailed Delivered <br /> APPLECANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 , <br />