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S 1.- <br /> Applications Will Be Processed When Submilted Properly Comple# 4 t sre To Siglsfl,�Application. <br /> ' '"�3FFICE USE: APPLICATIQ N, `' <br /> (For Non-Transferable, Revocable, ndabfgRR - vQ <br /> ENVIRONMENTAL HEALTH RMIT �5PUMP&W LL <br /> F <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY �� p��� <br /> r Application is hereby made to the San Joaquin Local Health Districtfvra permittoconstruct and!os sYfhework herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulation s of the San Joaquin Local Health District. <br /> Exact Site Address 4727 E. Cherokee City/Town <br /> Rd Stockton R <br /> W <br /> Owner's Name alter Emery <br /> Address same as above Phone <br /> f <br /> Contractor's Name Moorman' S Water Systems City <br /> License#267696 Business Phone 931-3210 <br /> Contractor's Address 4243 Cherr land. Ave. Emergency Phone same <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTIO, }❑ <br /> 11WELL CHLORINATION WELL ABANDONMENT ❑ OTHER ElPUMP INSTALLATION u PUMP REPAIR El <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> i. 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 <br /> ❑ GEOPHYSICAL Surface Seal Installed By: < <br /> PUMP INSTALLATION: Contractor <br /> ype of Pump Submersible H.P. z AdN <br /> PUMP REPLACEMENT: State Work Done install new pump <br /> PUMP REPAIR: ❑ State Work Done l �k <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 /> F <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 hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I wiLLpall for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X +' Title: L,� lea <br /> Date: _ • ��[J <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date 7 �y <br /> Additional Comments: <br /> Phase II Grout Inspection Pha III Final Inspection <br /> Inspection By Date - Inspection By <br /> Fee Is Due: ❑ ANNUALLY PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Fieceived By July 31 <br /> BASE' EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DDE CHECKED <br /> FEE <br /> ' AMOUNT <br /> iP Y.5 r� <br /> LESS r <br /> PRORATION <br /> PLUS F <br /> PENALTY <br /> OTHER <br /> OTHER <br /> _ s <br /> Received by _ —Date ..-Receipt No. �. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON_CA 952131 <br />