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Applications Will Be Processed When Submitted Properly Completed. Be Sure `TTo,Sign TheAppucatlo FOR OFFICE USE:-" APPLICATION R `� I-2-PO-f3 f3 YYY (For Non-TransferablW� evozable,Suspendable) PUMP&/EL ENVIRONMENTAL HEALTH PERMIT �+ r .- R.QUALITY l v`� � U � (COMPLETE IN TRIPLICATE) p p {_ 1-416;P-1 j� t-c .- 'raaas. Application is hereby made to lhe�an Joaquin Local Health Distrlctfiora permitto construct and/ all the�e�n�descryE application is made in compliance wit San Joaquin County Ordinance No. 1882 and the rules and regu_ Ions of the San a in ocal H'eaa th District. Exact Site Address .SIS Hwy. 26,zway between Shel &Wiener dky/Town Linden about 1 mile west of county line. Phone 931-0237 Owner's Name Earl Loveday Address scucity Sto-ckt_ Contractor's Name License#267696 Business Phone 93-1-3210 Contractor's Address Emergency Phone Is Certificate of Workman's Compensatio Insurance on Vire With SJLHD? Yes-C No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRR REPLACEMENT❑ �`�' DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL. G,J i ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation i ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing Q IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Moorman' s Water Systems Type of Pump su ersible pump end onlY H.P. PUMP REPLACEMENT: ❑ State Work Done pulled pump and install pump end PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure Joaquin County I hereby certify that I have prepared this application and that the work well be done in accordance with San Joa q 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." i Contractor's hiring or sub-contracting signature certifies the following:1 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 will 11 f��an rad final inspection. �^ �y / (� Signed X Title: '�� -� Date: .J -a2 Cep `d/ on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I -0�',pf Application Accepted By' Date Additional Comments: o Phase II Grout inspection Phase III Final Inspection Inspection By Date Inspection By Date Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 $,Received By July 31 !L REMIT BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS PRORATION PLUS M r r PENALTY OTHER OTHER - Received by Date Receipt No. Permit No Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AYE„P.O.Box 2009 STOCKTON,CA 95201