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,citations Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. APPLICATION (For Non-Transferable, Revocable, Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT i (COMPLETE IN TRIPLICATE) WATER QUALITY ti 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 ii compliance with San Joeguin COU qty Ordinance No.'1862 and the rules and regulations of the San Joaquin Local.Health District Exact Site Address 6553 Waterloo-Rd. ' City/Town -Stockton Owner' Frank Medina_ Phone 931-35 23 s Addresl8 same - City Contractor's Name Moorman/IS Water Systems License lt 267696 Business Phone 931=3210 Contractor's Address 4243 Cherryland Ave Emergency Phone game i Is Certificate of Workman's Compensation Insurance on File With SJLH07 Yes X No ; TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN❑ RECONDITION❑ DESTRUCTION13 WELL 1�,`,'HLORINATION ❑ WELL ABANDONMENT 13 OTHER 11 PUMP INSTALLATION lJ PUMP REPAIR REPLACEMENT❑ DISTA CE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Feld Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well J_ I+ENDED USE TYPE OF WELL - ❑ INDUSTRIAL ❑ CABLE TOOL - Dia. of Well Excavation —- _ ❑ DOf1MESTIC/PRIVATE ❑ DRILLED Dia.of Well Casing 13DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 1 -. ❑ IRRIGATION ? ❑ GRAVEL PACK Depth of Grout Seal ❑ CA' HODIC PROTECTION ❑.ROTARY Type of Grout - ❑ DISPOSAL 13OTHER Other Information 11GEOPHYSICAL Surface Seal Installed By: PUMP IN W LLATIO Contractor MOOrmari 1 s Water Systems '. �•� Type of Pump submersib a H.P. 3/4 s PUMP REPLACEMENT= X3 State Work Done pulled existingum and installed new PUMP REPAIR: _ ❑ State Work Done _ - DEST UCTION OF WELL: - Well Diameter Approximate Depth 1 '1 Describe Material and Procedure I hereby ce�ify that I have prepared this application and that the work will be done in accordance with Sen Joaquin County ordinances state laws, aod-rules.and regulations of the Sen Joaquin Local,Health District.. Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for wHich this permit is issue I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contraelors hiring or sub-eonlraoting signature certifies the following:"I certify that in the performance of the work forw"hieh 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. _ SigneA'X Title: 42- eg &r7 A� _ Date: S a3^ 9 (Drew Plot Plan on Reverse Side) ' y FOR DEPARTMENT USE-ONLY Y PHASE Application Accepted By 4 Date 0. Additional Comments: -S. ' Phase 11 Grout Inspects n Phasi 11 I al Inspeclion 9 Inspection By Date Inspection By ate l -Z13D Y`1 .Fee Is DNe:❑ ANNUALLY. ❑ PER UNIT )0 PER SITE ❑ EACH ❑ l ",y 1!.Received By Ja ry 31 ❑ July 1 a Raceivio By July 31 w REMIT BASE EXPLANATION BILLING REMITTANCE E AMOUNT DUE H UM DATE DATE REMITTED i FEELE PRS ION - ` I PLUS A"* d PFNAITr 9 OTHER OTHER 0 9k 2, a h 4 Rmeivee ey - Oa1e ^R cox No. Permit No lesuance Deo MOW Defirered •. APPLICANT— N ALL C;M TO, i IaIY1RONMENTAL HEALTH PERMITISERViCES teal E.NAZELTON AVE,►.O.BR Tea! STOCIITON.rA ssTal it