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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> FOR OFFICE use: APPLICATION <br /> (For Non-Transferable,Revocable,Suspendable) PUMP&WELLf <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 1�811. 'E• "Co er0 oliS Rd. City/Town Stockton <br /> Owner's Name Charles,Horn " ' ' Phone 948-6150 <br /> Address 'r- e-s City <br /> Contractor's Name Moorman'4 W3.ter' "S stems License 0267696 Business Phone- - 931-3210 <br /> Contractor's Address l Emergency Phone <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 5d PUMP REPAIR 13 <br /> REPLACEMENT R <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> 1 r'% <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> 'r # Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ NDUSTRIAL .. w ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> [[[❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 0-IRRIGAT-ION=-e---�- ---, --❑ GRAVEL-PACK - Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY 1 Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Moorman e s Water Systems <br /> I - Type of Pumsubmersible H.P. } <br /> p <br /> PUMP REPLACEMENT: State Work Done pulled existing pump and replaced With new 1H X <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> } Describe Material and Procedure- <br /> .a I <br /> I hereby certify that I have preparedithis 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 cbrtifies 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 srnia" <br /> ubject to workman's compensation laws of Califo <br /> I will call for a Grout Inspection prior to`grouiing and a final inspection. +, <br /> r , f pate: <br /> Signed X - Title: <br /> 3 _ (Draw Plot Plan on Reverse Side) r <br /> s FOR DEPARTMENT USE ONLY <br /> PHASE If 1 1 'a+ <br /> Application Accepted By �,J� Date t l <br /> Additional Comments: i <br /> Phase II Grout Inspection r Phase NI Fina! Insp trop <br /> ddd - r a l�-36 ` <br /> Date Inspection lay Date <br /> S <br /> Inspection By _� _ -- <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July r &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE £ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> LL +3 <br /> FEE J <br /> LESS <br /> PRORATION <br /> --PLUS <br /> PENALTY <br /> OTHER x.r <br /> hi <br /> OTHER r <br /> Received by Date Receipt No, Permit No. Iss ance Date Mailed Delivered <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />