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ApplicationsWill tae Processed When Submitted Properly Completed. Be Sure To Sign The Application, <br /> FOR OFf;kirE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> I (COMPLETE IN TRIPLICATE) WATER QUALITY / <br /> Application is hereby made tothe San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> i 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 4943 Paltrier City/Town Stockton <br /> Owner's Name Clyde Finney 11 Phone <br /> a3l -3378 <br /> Address Samt3 II City <br /> 'Contractor's Name Moorman r S Water S stem ^ <br /> l <br /> Contractor's Address 4243 Cherr__ 7, _ d-Afire S_ License Business Phone <br /> _ 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 CHLORINATIONI& 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 U <br /> Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL 0 CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED <br /> Dia. Well Casing <br /> 11DOMESTIC/PUBLIC 1:1 DRIVEN <br /> 11 IRRIGATION � Gaugea of Casing <br /> GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION �0 ROTARY <br /> DISPOSAL Type of Grout <br /> ❑ ❑ OTHER Other Information i <br /> ❑ <br /> GEOPHYSICAL .-� �urface Se Installed By: ) <br /> PUMP INSTALLATION: Contractor N - <br /> Typepf Pump r P <br /> PUMP REPLACEMENT: State Work Done U11 C �� <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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 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 compensatipn laws of California." <br /> I wi all for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X Title:4!11;1— p�J <br /> (Draw Plot Plan on Reverse Side) Date: j <br /> PHASE FOR DEPARTMENT USE ONLY <br /> Application Accepted By Q✓tiQ$._. c,>-a— <br /> Date <br /> Additional Comments: - <br /> a <br /> Phase 11 Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT - <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> EEE . / f AMOUNT <br /> LESS =� <br /> PRORATION <br /> PLUS <br /> PENALTY t <br /> OTHER <br /> OTHER <br /> Ii <br /> M ,• — S <br /> Received by Date i Receipt No. Li <br /> Permit No, Issuance Date <br /> Mailed Defiveretl <br /> • APPLICANT-=RETURN ALL COPIES TO:—�ENVIRONMENTAL HEALTH PERMITlSERYICES } <br /> - f 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />