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I ApplicationsWill Be Processed When Submitted Properly CompltB" ureTo SignTheAppllc uun. <br /> r FOR OFFICE USE: APPLICATION �UN 23 1980 <br /> (For Non-Transferable, Revocable,Suspendabl <br /> �.� .RUMP&WELL <br /> ' ENVIRONMENTAL HEALTH PE IT joti.lm LOU <br /> Q <br /> WATER QUALITY TH l7�STR`�T <br /> (COMPLETE IN TRIPLICATE) ; ' HEAL <br /> Application is hereby madeto the San Joaqui n 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 9980 N. Davis Rd. City/Town <br /> stockton <br /> p' 47B-5475 <br /> Owner's Name Gary Stolle Phone <br /> Address Sallie City s ame <br /> — <br /> f Contractor's Name Moorman Is Water sy5tmeS License# 7676961 Business Phone <br /> k <br /> Contractor's Address . 4243RCherr�land _ Emergency Phone _Saipp <br /> } Is Certificate of Workman's Comptensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): P W WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION W PUMP REPAIR❑ <br /> I REPLACEMENT❑ <br /> DISTANCE TO NEAREST: 5�ptic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property tine Private Domestic Well Public Domestic Well <br /> i INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL I ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ( ❑ DOMESTIC/PUBLIC <br /> ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL I ❑ OTHER Other Information <br /> El GEOPHYSICAL Surface Seal Installed By: <br /> M <br /> PUMP INSTALLATION: Contractor <br /> Moorman' s Water Systems 1,"ll <br /> Type of Pump 1 Su lller5l e <br /> PUMP REPLACEMENT: ❑ State Work Done removed exisiting pump and installed new One C <br /> i. <br /> PUMP REPAIR: ❑ State Work Done <br /> I <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> r 5 <br /> Describe Material and Procedure <br /> d <br /> f <br /> I hereby certify thaVI have prepared this application and that the work will be done in accordance with San Joaquin County <br /> i ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> } <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 will ali for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X Title: Dale: <br /> I, (Draw Plot Plan on Reverse Side) <br /> FO EPART ENT USE ONLY <br /> PHASE I Date <br /> Application Accepted ByrInn <br /> Additional Comments: ^L <br /> Phas Grout Inspection a 111 F al Inspection <br /> Inspection By !M Date Inspection By Date — <br /> ' Fee IS Due: ❑ ANNUALLY I� ❑ PER UNIT LF PER SITE ❑ EACH ❑ January 1 &Received By January ❑ July 1 &Recewed By July 31 <br /> F tBASE REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> EXPLANATION DATE DATE REMITTED <br /> AMOUNT <br /> -FEELESSPRORATIdNPLUSPENALTYOTHEROTHER <br /> Received 6y _s Date -� T,Receipt No. - Permit No. Iss ante Date Mailed Delivered <br /> Il. <br /> APPLICANT—RETURN ALL COPIES TO,. ENVIRONMENT9 STOCKTONu CA 95201 <br /> AL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 200 <br />