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: I <br /> Applications Will Be Processed When Submitted Properly Completed—Be %- <br /> ��r@"f-d�51 T �At li tion. <br /> FOR OFFICE USE: APPLICATION S - <br /> : } �. <br /> (For Non-Transferable, Revocable, ud able) <br /> ENVIRONMENTAL HEALTI1_WRMW R 6 1981 PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY -., Ijjm, 1-0-CAL <br /> �,. ,:. <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct aswinslifa�ll eyr�rJpelrfaTtiescribed.This application is <br /> made in compliance wi Sa Joaquin Coynty rdinance No. 1862 and the rules and re uiati bl e�anUUJttoaquin Local Health District. <br /> Exact Site Address tBo�b Moncrxef) 6603 E. Cherokee Rd. City/Town, Stockton <br /> Owner's Name Bob MOncrief Phone 931-2777 <br /> Address 6603 E. C ero ee R city_ Stockton oQ <br /> Contractor's Name Moorman's Water Systems License#267696 Business Phone 931--321.0 <br /> Contractor's Address ­4243Cherryl A-ye. 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❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 11C <br /> REPLACEMENT❑ <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 /> ❑3NDUSTRIAL ❑ CABLE TOOL pia. 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 Moorman' s Water Systems <br /> Type of Pump— �qUbLlltmrSi h] e H.P. <br /> ❑ State Work Done pul I ed pump and rep! aced. broken adaptor <br /> PUMP REPAIR: ❑ state Work Done replaced pumpQ <br /> B Well Diameter Approximate Depth lJJ <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 /> Homeowner or licensed agent's signature certifies the following:1 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 wi call for a Grout Inspection prior to grouting and a final inspection. f <br /> Signed X � Title: *� �' Date: �— <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I jj-- <br /> Application Accepted By ��AA_ <br /> © Date 4— v' <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Fi I Inspection <br /> Inspection By Date Inspection By ar-� Date '? <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE �-� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No, Iss once )Ate Mailed Delivered <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E,HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />