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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignleApplication. --FOR &F5:FICE USE: APPLICATION (For Non-Transferable, Revocable, Suspendable) ! ENVIRONMENTAL HEALTH PERMIT PUMP&W A (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address 10453 HiWay 26 City/Town Stockton Owner's Name Ron Orr Phone 932-1360 Address same as above city Stockton ' Moormans Water systems Contractor's Name License# 267696 Business Phone 931-3210 Contractor's Address 4243 Cherryland Ave. Emergency Phone ,t Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No t+ i TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ A, r WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION W PUMP REPAIR❑ REPLACEMENT❑ + DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy w Sewage Disposal Field_ Cesspool/Seepage Pit Other JR Property Line Private Domestic Well Public Domestic Well l INTENDED USE TYPE OF WELL ❑ JNDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC TO DRIVEN G uge of Casing _. I ❑ IRRIGATION }❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout 1' ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: res •[� PUMP INSTALLATION: Contractor Moorman's Water Systems �y TT,YPe�f Pump submersible motor H.P." 3 PUMP REPLACEMENT: L�State Work Done Pu11 pMTp and replace motor and control box 'J PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Q Describe Material and Procedure i I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this permit is issued, I shall employ persons subject to workman's compensation laws of California." I wil call for a Grout Inspection prior to grouting and a final inspection. ,�]7 Signed X Title: Date: 9" : (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY I PHASEI . Application Accepted By Date Additional Comments: i Phase it Grout Inspection s fi Inspection Inspection By - Date Inspection By x Date r9 f Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 BILLING REMITTANCE s $ REMIT - BASE EXPLANATIONS` AMOUNT DUE CHECKED DATE DATE REMITTED Y AMOUNT FEE i F LESS PRORATION PLUS PENALTY .OTHER OTHER Received by Date Receipt No. . .Permit No, Issuance Date Mailed Delivered - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2604 STOCKTON,CA 95261 33