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Applications Will Be Processed When Submitted Properly Completed. BeSureToSign TheApplication. <br /> ff7! <br /> OF­­E APPLICATION <br /> (For Non-Transierable, Revocable, Suspendable) !I <br /> � PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> i <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 5279 E. Cherokee Rd City/Town Stockton <br /> t Owner's Name Mrs. Pearl Morena Phone 9337 - <br /> Address 5221 E. Cherokee Rd. City Stockton <br /> Contractor's Name Moorman' s Water Systems License# 2676 96 Business Phone 931_321.0 -- <br /> Contractor's Address <br /> 4243 Cherr land Ave. Emergency Phone Sa i 1 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELI]I DEEPEN 11RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ Q <br /> DISTANCE TO NEAREST: Septic Tar>�V Sewer Lines Pit Privy <br /> I Sewage Disposal Field Cess oop I/Seepage Pit Z Other <br /> Property Line ' Private Domestic Well )S Public Domestic Well <br /> i INTENDED USE TYPE OF WELL <br /> 4 ❑ INDUSTRIAL .CABLE TOOL Dia. of Well Excavation <br /> I ❑ DOMESTIC/PRIVATE ❑ DRILLED pia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 'IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> I ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Syrface Se I nsta led By: <br /> PUMP INSTALLATION: Contractor Yf S <br /> 7 Type of Pump P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> r PUMP REPAIR: El State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Descr'b Mat � ial and Pr�ed�re <br /> I hereby certify that I have prepared this applica o and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations o the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of thew rk 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 G t ection prior to grouting and a final Inspection. <br /> Signed X Title: <br /> 4 a z Date: <br /> / (Draw Plot Plan on Reverse S' e) <br /> FOR DEPARTMENT USE ONLY r� <br /> PHASE 1 `` Date , <br /> � Application Accepted By <br /> Additional Comments: <br /> Phase II Grout Inspection Phase 1 Final Inspection <br /> ��� <br /> Inspection By Date Inspectt <br /> i n By Dae <br /> f Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 $.Received By July 31 <br /> kk REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> 1 PRORATION _ <br /> if PLUS <br /> PENALTY <br /> OTHER <br /> I <br /> I OTHER <br /> {7 Y <br /> Received by Date Receipt No. Permit No. Issu nce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITtSERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 ' <br />