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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION `��✓r�-G (For Non-Transferable, Revocable, Suspendable) PUMP&WELL ENVIRONMENTAL-HEALTH PERMIT {COMPLETE IN TRIPLICATE) WATER QUALITY CPN# 0 r Qo -17 Application is hereby made to the San Joaquin Local Health District fora permit to construct and7or 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 ttet8l 'E. Highway' 26 City/Town Stockton jo Owner's Name 1. Phone . Address t- City Contractor's Name -Moorman' S Water System, License#_267696 Business Phone Contractor's Address ., t Emergency Phone 911-3210 } Is Certificate of Workman's Compensation Insurance on File With SJLHD? _Yes No ' TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR 13 C7 REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank w1{ Sewer Lines St Pit Privy Sewage Disposal Field Cesspool/Seepage Pit A�3��iL.0 Other_,,�P?y _Property Li ns f Private Domestic Well Public Domestic Well INTENDED USE �. TYPE OF WELL ❑ INDUST.RIAL CABLE TOOLDia. of Well Excavation �� ❑ DOMESTIC/PRIVATE DRILLED Dia. of Well Casing '/r` ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing A l IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal CATHODIC PROTECTION ❑ ROTARY Type of Grout } ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL s Surface Seal .Installed By: _n 4— S PUMP INSTALLATION: Contractor Type of Pump H,P. I PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done . DESTRUCTION OF WELL: Well Diameter Approximate Depth i Describe Material and Procedure 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." 4 I will call fora Grout Inspection prior to-grouting and a final inspection. K Signed X'- Title: CO-Owner Date: 4-5—$3 (Draw Plot Plan on Reverse Side) t • FOR DEPARTMENT USE ONLY n �] PHASE I sLr V Application Accepted By ✓✓ �iv�'v�"`� Date Additional Comments: - Phase It Grout InspectionN as I Fin Inspectlon Inspection By � ; Date Inspection By �' Date l Fee Is Due: ❑ ANNUALLY ,- ❑ PER UNIT. ❑ PER SITE ❑ EACH' '❑ January 1-&Received'By January 31 ❑ July f &Received By July 31 BILLING..' REMITTANCE $ REMIT BASE EXPLANATION DATE DATE REMITTED. AMOUNT DUE CHECKED pp AMOUNT 1 FEE LESS - PRORATION PLUS a PENALTY OTHER - _ - _..,.-4- OTHER Received by Date Receipt No. Permit-No. - Is once Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201