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Applications Will Be Processed When Submitted Properly Comp SVfre To Sign pplication. i <br /> FOR OFFICE USE: APPLICATION � �� <br /> x (For Non-Transferable, Revocable, Sus blet ! <br /> 1� �gOAAP&WELL ; <br /> ENVIRONMENTAL HEALTH PERMIT a �,S . <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY J V��0 <br /> Application is hereby made tothe San Joaquin Local Health District fora permit to construct and/or inst'al'l 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 7163 Uyeda Rd. City/Town Stoekt 1 <br /> Owner's Name John Burdue Phone 931-2 80 <br /> Address Samt? MoormanCity <br /> Contractor's Name ' s Water S Stems License#367696 Business Phone <br /> Contractor's Address 4243 Cherryland Ave. Emergency Phone same <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT © OTHER ElPUMP INSTALLATION C1PUMP 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: E <br /> PUMP INSTALLATION: Contractor Moorman' s Water Systems E <br /> Type of Pump submersible H.P. 3 � <br /> PUMP REPLACEMENT: ❑ State Work Done replaced the motor <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich 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 <br /> I wilt call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X � <br /> Title: e Date: C <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date . <br /> Additional Comments: <br /> Phase II Grout Inspection �P a III F I Inspection z <br /> Inspection By Date Inspection By Date <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January t &Received By January 31 ❑ Jury 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br />' FEE ys <br /> I LESS <br /> PRORATION I <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> i. Received by - Date Receipt No. Permit No. I suance Pate - Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES •- 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />