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Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSignTheADM tion. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Traferable, Revocable,Sutpendable) Q�P3JMP&WELL <br /> ENVIRONMENTAL HEALTH.PERMITJA� ZI;'�-�" (3�,�, <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY � ��� <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or instalRbe work0eT@in described.This application is <br /> made in compliance with San Joaquin County Ordinance No.1862 and the rules and regulatioffs jbfth.q S,AN1%Joaquin Local Health District. <br /> Exact Site Address 277 N. Sibley City D to <br /> Owner's Name Tany F�uintel Phone — qJ1 = 1, <br /> Address same City l7� <br /> Contractor's Name Moorman' a Water qyqtemq License# 267FC3h Business Phone931.,. 3910 (,m � <br /> Contractor's Address 2120 Wilcox Rd. Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes�x No <br /> TYPE OF WORK (CHECK): NEW WEL13 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR <br /> REPLACEMENT❑ It <br /> DISTANCE TO NEAREST: Septic Tank.. Sewer Lines o Pit Privy <br /> Sewage.Disposal Field eeaap"I/Seepage Pit Other <br /> Property Line�O Private Domestic Well �"^' Public Domestic Well �r <br /> INTENDED USE TYPE OF,WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL' { Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ^ 4 DRILLED Dia. of Well Casing <br /> DOMESTIC/PUBLIC DRIVEN Gauge of Casing V <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout _ 'P0 <br /> ❑ DISPOSAL OTHER Other Information ' <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor MOOrman' S Water Systems <br /> Type of Pump suhMer i b 1 H.P. I <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 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: -l'& Date: <br /> (Draw Plot Plan on Reverse Side) <br /> F FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments:• ; <br /> P e II G ut Inspection J3 se III inal <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE 0 EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> I REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT.DUE CHECKED <br /> 1 <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 0A k&n <br /> Received by Date Receipt No Permt No, Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SER ICES 1601 E.HAZELTON AVE.,P.Q.Box 2009 STOCKTON,CA 95201 <br />