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Ap IedonsrYl, lt�eTSroc� i)When Submitted Properly Completed.Be Sure To Sign The Application. <br /> FOR OFFICE USE: 11�~CC DD APPLICATION <br /> A t ���(f"ALTransterable, Revocable, Suspendable) <br /> SAN JC Q PUMP&WELL <br /> HEAL-fH DISIWRONMENTAL HEALTH PERMIT oc <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 382 Patton Rd. City/Town Stockton <br /> Owner's Na Joe Lizama Phone 464-9531 <br /> Address 382 Patton Rd. City Stockton <br /> Contractor's Name Moorman s Water Systems License#267696 Business Phone 931.--3210 <br /> Contractor's Address 4243 Cherry.land Ave. Emergency Phone rt n <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRU ❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ STALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank _ Sewer Lines _- Pit Privy f <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL I <br /> ❑ ❑ CABLE TOOL Dia. of Well Excavation <br /> STIC/PRIVAT ❑ DRILLED Dia, of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> © IRRIGATION ❑ GRAVEL PACK Depth of Grout Sea) <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Stjrface e I lns Iled By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 4� <br /> PUMP REPLACEMENT: ❑ State Work Done <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 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." �? <br /> I will call for rout n ec' n pnoVo grouting and a final inspecti n. <br /> Signe Tltle: ,. Date: —Ilse <br /> p �` <br /> (Draw Plot Plan on Reverse Side) <br /> FO DEPAR ENT USE ONLY <br /> PHASEI _ <br /> Application Accepted By Date L2 5 6 <br /> Additional Comments: <br /> Phase II Grout Inspection / ase 111 Oln <br /> coon x0 1 �0 <br /> Inspection By Date Inspection By <br /> Fee I5 Due: El ANNUALLY El 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 /> �f AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance 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 />