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ApplicationsWill Be Processed When Submitled Rro erl `Com <br /> R Y p r To Sign <br /> FAR.OFF.ICE USE: - APPLICATION 1 'WppHcation. <br /> (For Non-Transferable, Revocable, 4' <br /> ab101 lN\1 <br /> ENVIRONMENTAL HEALTH PERMIT Jar4 D 5��1MP&WELL �` <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY S 1V R�'(N 4, <br /> Application is herebymadetotheSanJoaquinLocalHealthDistrictforapermittoconstructand/orins4heworkhereindescribecf.Thisapplicationis f <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 6717 E. Cherokee Rd. City/Town Stockton <br /> Owner's Name Gary Gustafson <br /> Address Sane Phone 931-5085 <br /> � City <br /> Contractor's Name Moorman' s Water S sty License# 267696 Business Phone 933-•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❑ DESTRUCTION❑ �I <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPA IR❑ D, <br /> REPLACEMENTZ <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 <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor e <br /> Type of Pump su mer81 a H.P. �- <br /> PUMP REPLACEMENT: ❑ State Work Done replaCed pump with new l HP <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 /> 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 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. <br /> Signed X T 2 Title: - Date: — <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By pcg= <br /> Date <br /> Additional Comments: <br /> Phase Il Grout Inspection P as 11 Fin t Inspection <br /> Inspection By Date Inspection By Date Z <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 <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEEVL e12 <br /> 4__� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 3 <br /> Received by Date Receipt No. Permit No. Issuanc Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />