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Appl' �i n�V I t rues d±eZPPLICATION <br /> itted Properly Completed. Be SureToSi TneAppncac�an. <br /> V.//—�J",FOR OFFICE USE: r Noferable, Revocable,Suspendable) PIMP&WELL i <br /> -� <br /> SEP 8 1� <br /> VIRONMENTAL HEALTH PERMIT x <br /> (COMPLETE IN TRIPLICATE)SAIN JOAQUIN LOCAL WATER QUALITY <br /> a �Istrictfora permit to construct and/or instal Ithe work.herein described.This application is <br /> Application is hereby made to the�1A�,��n�� <br /> made in compliance with San Joaquin County Ordinance No.1862 and the rules and regulations of the Sa StOCktQnJoaquin i Health District, <br /> Exact Site Address 9622 E. 8 Male Rd/ City/Town <br /> ' Name <br /> xarr Parks Phone 213-923-3634 <br /> Acity Downey, Calif <br /> Address 9208 Lubec � . <br /> Contractor's Name Moorman' s Water S stems License# 26 7696 Business Phone 931-3210 <br /> Contractor's Address 424 3 Cherryland Ave Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X <br /> No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ PUMP REP <br /> WELL CHLORINATION 13 WELL ABANDONMENT ❑ OTHER 11 PUMP INSTALLATION © <br /> REPLACEMENT{? t <br /> Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank <br />` Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well <br /> Public Domestic Well <br /> NTENDED USE TYPE OF WELL <br /> ❑ 1 DUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ D MESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ D MESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ 1 IGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ C THODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ SPOSAL ❑ OTHER Other Information <br /> ❑ EOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Moorman' s Water Systems <br /> Type of Pump submersible H.P. z <br /> PUMP REPLACEMENT: ER State Work Done re Ilaced old e ui . with new um <br /> PUMP REPAIR: 11 State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: <br /> Well Diameter <br /> Describe Material and Procedure <br /> I hereby certify that I 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 /> f is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> I Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> i permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout inspection prior to grouting and a final inspection. <br /> r " Date: <br /> Signed X Title: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DE=PARTMENT USE ONLY <br /> f PHASE I Date <br /> Application Accepted By —;I <br /> Additional Comments: <br /> Phos out Inspection ---Phase,lll Final Ins eciion <br /> Inspection By Date <br /> Inspection I3 / Dated By <br /> �4���� <br /> Fee Is Due: 13ANNUALLY ❑ PER UNIT - ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveREWTuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 5� <br /> LESS <br /> PRORATION <br /> PLUS <br /> I PENALTY <br /> OTHER <br /> OTHER <br /> Received by <br /> Date Receipt No. ermit No. I uance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: -ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />