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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable,Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> 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 <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 5252 E. Ashley Lane City/Town Stockton <br /> Owner's Name Mr. D. Williams Phone 931-1570 <br /> Address same City <br /> Contractor's Name Moorman t s Water Systems License# 267696 Business Phone 931-3210 <br /> Contractor's Address 2120 Wilcox Rd. Emergency Phone f.l <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❑ /n <br /> WELL CHLORINATION ❑ WELL ABANDONMENT❑ --OTHER❑ PUMP INSTALLATIONOC PUMP REPAIR❑ V <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 /> 11 DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION Q ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Moorman`s Water Systems <br /> Type of Pump submersible H.p. 2 <br /> PUMP REPLACEMENT: 127ftate Work Done replaced existing um With new 2HP <br /> PUMP REPAIR: ❑ State Work Done ; <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure __ m <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 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 will call for a Grout Inspection prior to grouting and a final inspection. _ <br /> Signed X Title: & -el2e,n•Q./ Date: .S 0174 3 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - _.. .. ___;a„, _ _ ._ _ _ _... <br /> 16 <br /> Application Accepted B Date <br /> 3 <br /> Additional Comments: <br /> Phase II Grout Inspection Phas Il Final Inspection <br /> Inspection By Date Inspection.By Date. 6 `Ty <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE S L S� <br /> LESS <br /> PRORATION <br /> PLUS {{ � UWWb.V I <br /> PENALTY � 2 Z — C.ci..i.1�r!".,�.. ,�, C..t ti�� I-< ",'J d,6 � �^- <br /> OTHERr�- <br /> 0 <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuant Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,C• <br />