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"13n'rW11IBe Processed.I"submitted Properly Completed. BeSureToSignTheApplication. <br /> FOR OFFICE USE; p� APPLICATION <br /> QST 2 q�1 OO or Non-Transierable, Revocable, Suspendable) <br /> Mile <br /> PUMP&WELL <br /> A r ,fIN LgeNLRONMENTAL HEALTH PERMIT <br /> Oil <br /> ICATE)H I 1 TH C} TRgGT WATER QUALIFY <br /> (COMPLETE IN TRIPL <br /> t I��,- <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 Sanui °cal Health District. <br /> Exact Site Address <br /> City/Town �c�con <br /> Owner's Name Phone <br /> Address lLe KO- City d <br /> Contractor's Name Moorman s Water Systems License#?6'7696 Business Phone — <br /> A.V'e. <br /> Contractor's Address C erry axl Emergency Phone SaTSIe <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION-0 WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT: <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 /> I PUMP INSTALLATION: Contractor Moorman' s Water Systems <br /> Type Of Pump H.P. <br /> pulled PUMP REPLACEMENT: i � � State Work Dane ulleci p1�mp and installed new. motor -S) <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that F 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 wSray for a I ection prior to grouting and a final Inspection. <br /> Title: Co—Owner Date: g—29-80 <br /> (Draw Plot Plan on Reverse Side) ` <br /> FOR DEPARTMENT USE ONLY <br /> f PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection Wase it Final Inspection <br /> Inspection By Date Inspection By ate 10 —<Rd <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July i &Received By July.31 <br /> + REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> ,i 10 <br /> FEE <br /> LESS <br /> PRORATVON ' <br /> pI PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No Permit No. I sua a ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 ,STOCKTON,CA 95201 .5 <br /> - - t <br />