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FOR OFFICE USE: �I, SEP 8 __ � APPLICATION i1rZo29114 T � rNon-Transferable, Revocable, Spspendable) SAN JOA t;fN ET fflONMENTAL HEALTH PERMIT - PUMP&WELL (COMPLETE IN TRIPLICATE) HEALTH DISTRICT WATER QUALITY Application is hereby made to the San Joaquin Local Health District fora 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 11055 N Highway 88 .. City/Town Stockton Owner's Name J. Koster Phone Address City 9,5 (� o Contractor's Name Moorman' s Water 6YSteMS License# 267696 Business Phone 931-321.0 Contractor's Address _42-4.3 Cherry an Ave Emergency Phone i Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X-- No 'J TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR CJ" 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 IN USE TYPE OF WELL DUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation D MESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ D MESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IR IGATION ❑ GRAVEL PACK Depth of Grout Seat ❑ C THODIC PROTECTION © ROTARY Type of Grout ❑ SPOSAL ❑ OTHER Other Information ❑ EOPHYSICAL' Surface Seal Installed By: € Ct MP INSTALLATION: Contractor Moorman' s Water Systems Type of Pump Submersible H.P. 1 PUMP REPLACEMENT, x❑ State Work Done u11ed existing Um and re laced W th ew One PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth 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." I will call for a Grout Inspection prior to grouting and a final inspection. Signed X - t�T✓ Title: e,&— L!/.lJC�7f��._... Date: ',y l// (Draw Plot Plan on Reverse Side) ` ,l FOR DEPARTMENT USE ONLY CSV PHASE I .i _,o—8 Application Accepted By ` Date Additional Comments: Phase II Grout Inspection hage i al I spection / Inspection By Date Inspection By 1 Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 BILLING REMITTANCE $ REMIT BASE EXPLANATION DATE DATE REMITTED AMOUNTDUE CHECKED AMOUNT FEE LESS PRORATION 1- PLUS PENALTY 1 OTHER 1 OTHER I Received by Date Receipt No. Permit No, Ins ante Dae - Mailed Delivered APPLICANT—RETURN.ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON.AVE.,P.O.Box 2009 STOCKTON,CA 95201