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-- Applications Will Be Processed When Submitted Properly Completed.'Be Sure To Sign The Application. - FOR OFFICE USE: APPLICATION (For Non-Transferable,Revocabte;'Suspendable) PUMP&WELL . ENVIRONMENTAL HEALTH PERMIT �\ (COMPLETE IN TRIPLICATE)t WATER QUALITY + �_ Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work 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 L block 1 fity/Town Owner's Name Gro pe Glass,- "`• - Phone Address 44201,!Grimm6r-'B1vd city-Fremont, Cal. 94,918 ^ � Contractor's Name Moorman I S +:Water tSVSbeMS License 6267696 Business Phone ' 9.31-3210 W Contractor's Address 2120 Wil6ox., Rd': "` 'Emergency Phone Is Certificate-of Workman's Compensation Insurance on File With SJLHD? Yes X No TYPE OF WORK (CHECK):--NEW WELL30 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELLBA ANDONMENT ❑ OTH'E'R ❑-� PUMP INSTALLATION{ PUMP REPAIR 13 REPLACEMENT❑ ---_ --.. r ` k DISTANCE TO NEAREST: Septic Tank Q Sewer Lines Pit-Privy Sewage Disposal Field �- Cesspool/Seepage Pit &gQ Other._ +� Property Line oqo� Private Domestic Well N_Adj� Public Domestic Well INTENDED USE TYPE OF WELL I^fe f INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 0 DOMESTIC/PUBLIC ❑ DRIVEN Gauge-of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 0 CATHODIC PROTECTION ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal installed By: f _ PUMP INSTALLATION; Contractor Moorman I ilaber Systems 4 Type of Pump H.P. 35 Submersibte PUMP REPLACEMENT: ❑ State Work Done ; "f• PUMP REPAIR: ❑ State Work Done ' DESTRUCTION OF WELL: Wetl `ameter ^Approxi.mate Depth 3 _ f - Describe Material and Procedure f 1 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.Pistrictx' + f* Home owner or licensed agent's signature certifies the following:"I certify that in the�erformanceof the work for which'this permit y Contractor's hiring or sub-contracting signature certifies the following:"I certify that!in the performance of the wotk-forw ich this is issued, I shall not employ any person in such manner as to become subject to workma��s corfipensation law,s of balifor�ia." permit is issued, I shall employ persons subject to workman's compensation laws of California.-" � t.+" 1 IL-for a rout Inspection p ' r to grouting and a final inspection. f--� lt Signed A Title: I Date: Z ( (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY I """" - - — j i k ��_..,.:..-... rraam� ^ ,�`� PHA E I Application ation Accepted By )VwLaa "° Date � Additional Comments: Lip- I has$11 Groutt Ins ection se, Firs Ins ection Inspection By �' "�' P �l ` � Ins ectionrDatp Y Feee l Due: ❑ ANNUALLY ' ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &'Received By January 31 ❑ July 1 &iReceived By Juiy 31 " BILLING , REMITTANCE.,. REMIT BASE EXPLANATION" � . � � + r –CHECKED- DATE � P,TE REMITTED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER &�� . Received by - Date Receipt No, Permit No. - If uance to Mailed _ Detivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITJSERVICES 1601 E.FlAZELTON AVE.,P.O.So-2009 STOCKTON,CA 95201