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W ubmitted Property Completed. Be Sure To SignTheApplication <br /> Applications Will Be Processed When S . <br /> APPLICATION / <br /> FOR OFFICE USE: yT <br /> (For Non-Transferable, Revocable,Suspendable) <br /> f PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY - <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health District for apermittoconstructah.d/orinstallthework herein'described.Thisapplicationis <br /> made in compliance with San Joaquin County Ordinance No.- <br /> and:the"_r6ies and regulations of the San Joaquin Local Health District. <br /> Exact Site Address <br /> 8635 N. Ste hens" Rd: City/Town <br /> Schimke •f;; 6 Phone <br /> Ken <br /> Owner's-Name , Cit OCA n <br /> Srame n• - y <br /> Address i Business Phone_ 931 32 'd . } <br /> It n License.#�{l..Z6��1-- <br /> Contractor's Name _Moorman s Wr�ter �C'S �ID�—' Emer enc IPhone. j= <br /> Contractor's Address 2120 Wi1c0X'Rd1 %%' s t .„Yip g y <br /> No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X. _ <br /> DEEPEN RECONDITIOId� <br /> TYPE OF WORK (CHECK): NEW WELL 0' ❑ INSTALLATION 1:1 PUMP REPAIR❑ 4 <br /> WELL CHLORINATION 11 WELL ABANDONMENT 13OTHER ❑ PUMP <br /> REPLACEMENT:❑ Lies Pit Privy <br /> Sewer n <br /> DISTANCE TO�NEAREST: Septic Tank <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public.� � Domestic Well ., f <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ INDUDOMSTRIAL <br /> NATE ❑ DRILLED Dia. of Well Casing <br /> ❑ Gauge of Casing <br /> DOMESTIC/PUBLIC ❑ DRIVEN y 1 <br /> ❑ IRRIGATION ❑ GRAVEL-PACK-- Depth of Grout Seal i <br /> ❑ CATHODIC PROTECTION 13 ROTARY Type of Grout ' <br /> 13 DISPOSAL <br /> 11 OTHER Other Information { <br /> Surface Seal Installed By: <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor Moorman s Water S Stems Vl <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT:, State Work Done - Withne-W 1 <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: <br /> - 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 iorwhich 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 /> i <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." . <br /> I <br /> I will all for a Grout Inspection prior to grouting and a final inspection. _ <br /> I <br /> � � i / Date: 5 <br /> Signed X Z-z� � Title: <br /> I (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> IFApplication <br /> `' Date <br /> Accepte 13yl Comme ts: p se IlIfFinal Inspection r <br /> Phase 11 Grout Inspection s1 Date <br /> haDinspection By <br /> Inspection By ate 1 13{ l <br /> Fee Is Due: ❑ ANNUALLY PER UNIT ❑ PER SITE ❑ EACH ❑ January i &Received By January 31 -❑ July i &Receiv REMIT11uIy1i' <br /> I BILLING REMITTANCE $ —AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE ... _ <br /> .�-^•LESS�" '"'„- ^°..."' ,..x � � "`_ " <br /> ` PRORATION <br /> r PLUS <br /> PENALTY <br /> OTHER <br /> FF' OTHER 2 <br /> _ _ Permit No. M aiSed Y Delivered ` <br /> Received by Date Receipt No. <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE,,P.Q.Box 2009- STOGKT+ON,CA <br /> APPLICANT—RETURN ALL COPIES TO: 95201 - <br />