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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION Y f (For Non-Transferable, Revocable;Suspendable) PUMP&WELL F .k ENVIRONMENTAL HEALTH'PERMIT `�� (COMPLETE IN TRIPLICATE) WATER QUALITY t/�G iI'.iftri fod tM Of Application is hereby made to the San Joaquin Local Health District for a permit to construct and/.or..installthe work..hereindescribed.Th application ISO-- made in compliance with San Joaquin County Ordinance No. 1862-and the rules and regulations•of the San Joaquin Local Health District. _ vt v Exact Site Address 3823 Surfn Rd_ x City/Town StocktQri � n Owner's Name John Pile Phone r ' Address Salflf?�: '-:J ';:. . } ,> 1t. City Contractor's Name MoormanI Jgwate'r '8ySteMA License#20`6g6 ��'tBusiness Phoney' 931"3210 2120 ,Wi'lco*2 R& r -. g Eniergency Phone` "1 Contractor's Address - l Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No 7. _ - - - TYPE OF WORK (CHECK):: NEW.'WELL❑ DEEPEN ❑ -RECONDITION❑DESTRUCTION WELL CHLORINATION ❑ WEL1L ABANDONMENT❑'OTHER ❑moi PUMP INSTALLATION PUMP REPAIR❑ O REPLACEMENT❑ jp DISTANCE TO NEAREST: Septio`Tank Sewer Lines Pit Privy Sewag"e Disposal Field Cesspool/Seepage Pit ( Other Property Line Private Domestic We11 Public Dolnestic}Well INTENDED USE �� TYPE OF WELL ; ❑ INDUSTRIAL n ❑ CABLE TOOL - Dia. of Well Excavation ❑ DOMESTIC/PRIVATE 1 ❑ DRILLED Dia. of Well Casing ) ❑ DOMESTIC/PUBLIC I 1! ❑ DRIVEN Gauge of Casing z ❑ IRRIGATION Ii ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION II ❑ ROTARY Type of Grout I - ❑ DISPOSAL ❑ OTHER p Other Information r�L� ❑ GEOPHYSICAL it Surface Seal Installed 13y: PUMP INSTALLATION: ji Contractor Moorman' s Water Systems i IIII Type of Pump submersible t' H.P. PUMP REPLACEMENT: 0 State Work Done pull turbine and ihstall new submersibl PUMP REPAIR: II 0 State Work Done f ; DESTRUCTION OF WELL: �i Well Diameter ' Approximate Depth 1lj Describe Material and Procedure I I 1 hereby certify that I have prepared this application and that the work will be done iri accordance with San Joaquin C;permit F ordinances, state.'iaws; and rules and regulations of'lhe San Joaquin Local Health District. k 4.., _ n Homeowner or licensed agent's signature certifies the following:1 certify that in the performance of the work for which this _. is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." - F ; i Contractor's hiring or suti-contracting signature certifies the following:"I certify that in the performance of the work for which this F permit is issued, I shall employ persons subject to workman's compensation laws of California." I will call for a Grout Inspection prior to grouting and a final inspection. I Alp signed X`� Title: /�.Ur�r/ii P Date: �.� (Draw Plot Plan on Reverse Side) ` I FOR DEPARTMENT USE ONLY PHA Application l ation Accepted By ��' Additional Comments: Phase II Grout Inspection fyhas�J►I11 Ins tion Inspection Byr Date I Inspection By ` .. } '"Fee Is Due: ❑'ANNUALLY ❑ PEAUNIT"-❑ PER SITE ❑ EACH [IJanuary 1 8 Received By January 31-' ❑ July 1 &Received By July 31 °!+ { BILLING .;, REMITTANCE REMIT BASE ` "EXPLANATION` DATE t AMOUNT DUE CHECKED r DATE REMITTED AMOUNT O FEE _ _ r•k ,� - LESS PRORATION _ .I PLUS - .i;. _ _ .4- - _ _ .r,_. ,,.� ;}•.. . .- - PENALTY OTHER i! _ _ OTHER - -;•'- "°- rr,=- .,. _... .. *:- .....r.,e .� �.i, ,.. 3 Received bye• Date .IReceipt No, Permit No. Issuanc Date L--y.Mailed Delivered x APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AYE.,P.D.Box 2009 STOCKTON,CA 95201