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Applications Will Be PrOCe&d When Submitted Properly Completed. Be Sure To Sign The Application. t <br /> FOR OFFICE USE: r APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> .w <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 aquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address Shattuck Track Rd City/Town <br /> ---�-^-� <br /> Owner's Name Pete Panos Phone <br /> Address 1825 Robert City <br /> Contractor's Name Moorman' s Water SYStam9_ License#267696 Business Phone 931-3210 <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes x No 1 1 <br /> TYPE OF WORK (CHECK): NEW WEL3c0 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ r� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION Q PUMP REPAIR❑ Cl <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 Weil <br /> INTENDED USE TE OF WELL <br /> DUSTRIAL ,�,��/G�BLE TOOL Dia, of Well Excavation <br /> DOMESTIC/PRIVATE LSDRILLED Dia. of Well Casing i�NG <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing z <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ! <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> 1:1 DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Moorman' s Water Systems <br /> Type of Pump. submers i bIP H.P. <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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, 1 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 /> 1 will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X Title: _,�� Q��Q�� Date: /Z <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted K*10. <br /> Date G3 <br /> Additional Comment <br /> Phase II t Inspects / ttas II! Final Inspection <br /> Inspection By Date �/� Inspection B Date <br /> ��j <br /> Fee Is Due: El ANNUALLY El PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Rece+ved By Januari <br /> y 31 ,� ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE cA <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 3- <br /> Received by Date Receipt No. Permit No Muell-ide 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 />