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Applications Wilt Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> FOR OFFICE USE: ;APPLICATIONCA _ <br /> (For Mort-Transferable,Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL 14EALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permitto constructand/or installthework 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 9425 N. Alhambra City/Town Stockton <br /> Owner's Name Don Mah Phone 931-5308 <br /> Address S m& City <br /> Contractor's Name`_ Moorman t s Water Syistelt8icense# 267696 Business Phone 931-3210 ) <br /> Contractor's Address 21 20 W 4.l e-0 Rd, Emergency Phone <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 ❑ PUMP INSTALLATION RUMP REPAIR❑ <br /> REPLACEMENT 13 <br /> DISTANCE TO NEAREST;' Septic Tank- Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> r Property Line Private Domestic Well .Public Domestic Well <br /> ANiENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia:of CV611 Mxcavafion <br /> :DOMESTIC/PRIVATE ❑ DRILLED Dia.of Well Casing <br /> d DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing I <br /> ❑ :IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 0 GEOPHYSICAL q �' Surface Seat Installed By: <br /> PUMP INSTALLATION: Contractor Moormans g Water $�aStlttt8 <br /> Typeof Pump 31bElex Siblfii! H.P. <br /> PUMP REPLACEMENT- ® State Work Done r9moy!Rd '4x4@ g pUM and roplaco with H <br /> PUMP REPAIR: State Workilim"` <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> F r _ <br /> Describe.RAater aI and Procedure- <br /> I he certify''that I have prepared this application and that tle work will be done in accordance with n Joaquin County <br /> ordinapces, state Jaws,and rules and regulations of the San Joalltuin Local Health District. <br /> Home pwner or licensed agent's signature certifies the#glowing:" Certify that in the performance of the work t r which this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's.compensat ri.faws of California .:. <br /> Contractor's hiring or sub-contracting signaturicertifies the folloyring:"I certify that in the performance df the Work for whichthis <br /> permit,is issued, I shall employ persons subject to workman's compensation laws of California. <br /> I tirilF ' q for a Grout Inspection prior to grouting and a final inspection j <br /> Signed XTitle: d �--x Pte✓ ate. ✓�" <br /> (Draw Plat Pian on Reverse Sidra) > <br /> f FOR DEPARTMENT USE ONLY <br /> PHASE 1 <br /> A,ppt�Catiol�Accepted`-$y , <br /> -.Date <br /> Aidditional Comments: <br /> Phase li Grout Inspect"' Phase W Final Inspection !` <br /> Inspection By A <br /> a Date Inspection By Date <br /> Fee Is Due: 0 ANNUALLY ❑ PER UNIT 0-PER SITE 0 EACH 0 January 1,&Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> i <br /> BILLING REMITTANCE $ AAO!BASE EXPLANATION UNT'DUE CHECKED <br /> DATE DATE REMITTED AMOLINT <br /> FEE $48. <br /> 9 <br /> LESS <br /> PRORATION', <br /> • <br /> PLUS <br /> PENALTY - <br /> OTHER <br /> OTHER <br /> 1 �, <br /> Received by Date' Receipt No., Permit No. I nce Da Mailed - Delivered <br /> APPLICANT—RETURN•ALL COPIES TO: I:NVIRONNENTAL HEALTH PP04T/SERVICES M1 E,.HAZELTON AVE.,P.Q,-8at 2000 STOCKTON,CA 95201 <br />