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Applications Will Be Processed When Submitted Properly Completed. Bei yr� Ig A "llc�` <br /> FOR OFFICE,U;E:, APPLICATION <br /> (For Non Transferable, Revocable, Sus b�e <br /> n - PUMP&WELL <br /> ENVIRONMENTAL HEALTH P T �� � 1 6 198 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY ^Q�11 fLt , h1,1L -1)Application is hereby made to the San Joaquin Local Health District fora permit to construct and/oSl if thvn10� N e gsdribed.This application is <br /> g K1v <br /> made in compliance with San Joaquin Cnllnry t'�rriinance No.1862 and the rules and regulations rN o L'acal Health District. <br /> Exact Site Address - 3507 _ City/Town Stockton <br /> Owner's Name JeSS Chappell Phone 478-2447 <br /> Address 2225 Navy Drive City <br /> Contractor's Name Moormans Water Systems License# 267696 Business Phone 931--3210 i <br /> Contractor's Address 4243 Cherr land Ave. Emergency Phone same <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 CHLORINAT ON ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <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 Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information �N <br /> ❑ GEOPHYSICAL Surface Seal Installed By: O <br /> PUMP INSTALLATION: Contractor Moorman' s Water Systems <br /> Type of Pump submersible H.P. <br /> �I <br /> PUMP REPLACEMENT: ❑ State Work Done replaced existing pump With Hp submersible <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter q l <br /> pproximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that ! have prepared this application and that the work will be done in accordance with San Joaquin County C`�k <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, 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 a Grout Inspection prior to grouting and a final inspection. <br /> Signed X , �_, Title: _4f�!F - Z9�27;2Z"_e _. Date: <br /> (Draw Plot Plan on Reverse Side) <br /> F DEP RTMEN USE ONLY <br /> PHASE I � /f <br /> Application Accepted By G'f' Date <br /> Additional Comments: <br /> Phase II Grout inspection Ph a III Final Inspection6 <br /> Inspection By Date Inspection By Date Zo <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS ~a <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuancd Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />