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15 Ap IlclI(A.VWI hlPlrocessetl"dVh bmitted Properly Completed. Be Sure To Sign The Application. FOR_OFFICE USE; �1 APPLICATION pp�� € SEP U ��Bdr Non-Transferable, Revocable, Suspendable) SAN �DAQ�J'IN E81�(fflONMENTAL HEALTH PERMIT PUMP&WELL I i (COMPLETE IN TRIPLICATE) HEALTH DISTRICT WATER QUALITY � Application is hereby made tothe San Joaquin Local Health Districtfora permit to construct and/or install thework herein described.This application is made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address 11055 N Highway 88 City/Town Stockton Owner's Name J. Koster Phone 9,33-2132 Address .1?y1J—/1 City_ SzmS 0,2 Contractor's Name Moormarir s water.._ steMS License# 267696— Business Phone 931-3210 _ Contractor's Address 4243 Cherryl and Ave Emergency Phone ) Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No ~y TYPE OF WORK (CHECK):— NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR c� REPLACEMENT€ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other E Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL DUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation D MESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing } ❑ D MESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IR IGATION ,a ❑ GRAVEL PACK Depth of Grout Seal ❑ C THODIC PROTECTION ❑ ROTARY Type of Grout i_ ❑ SPOSAL ❑ OTHER Other Information ❑ EOPHYSICAL Surface Seal Installed By: 1,111 w MP 4 INSTALLATION: Contractor Moorman t 5 Water Systems I Type of Pump submersible H.P. l +� PUMP REPLACEMENT: X❑ State Work Donepulled existing um and re laced w thnew One PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth i Describe Material and Procedure a I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Homeowner or licensed agent's signature certifies the following:A certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature Certifies the following:"I certify that in the performance of the work forwhich this permit is issued, I shall employ persons subject to workman's compensation laws of California." I will call for a Grout Inspection prior to grouting and a final inspection. Signed X Title: Date: ._ (Draw Plot Pian on Reverse Side) .xs FOR DEPARTMENT USE ONLY PHASE E VqNU, Application Accepted By � - Date — Additional Comments: Phase 11 Grout Inspectionha4e i al I spection f / Inspection By Date Inspection By Fee Is Due: El ANNUALLY ❑ PER UNIT El PER SITE El EACH ❑ January 1 &Received By January 31 El July 1 &Received By July 31 BILLING REMITTANCE $ REMIT BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED - AMOUNT cj FEE r I LESS PRORATION PLUS PENALTY OTHER OTHER ci Received by Date Receipt No Permit No. )ss ante Da a Mailed. Delivered _ .4 } APPLICANT—RETURN ALL COPIES TO: .ENVIRONMENTAL HEALTH.PERMIT/SERVICES.a - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 11.