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FOR OFFICE'USE.- AUG I6 198(p APPLICATION n � r 1,11-or Non-Transferable, Revocable, Suspendable) 1 PUMP&WELL e Sj;11 LOCIlyl RONMENTAL HEALTH PERMIT I (COMPLETE IN TRIPLICATiJF_-'k -TH 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 4354 N. Newton Rd. City/Town S_tQA=kt0_n_ __ i Owner's Name r Phone .. 977 Address P—O _ City StoCkton Contractor's Name MoormarlI g Water 5V.St OMS— License#267696 Business Phone_ 931– X21 Q I Contractor's Address Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_-x No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ �} WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION C PUMP REPAIR❑ REPLACEMENT Q 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 y❑ INDUSTRIAL •, ❑ CABLE TOOL Dia. of Well Excavation ral DOMESTIC/PRIVATE ❑ DRILLED Dia.of Well Casing ❑ DOMESTLC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ 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 H,P PUMP REPLACEMENT: :7 State Work Done pu I I edxt-.isil.ng ymp and rep1ac-ed!wdtJi_nem nne PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth a Describe Material and Procedure 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 for which 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 s 1–� Title; - -- E=x ,f Date• / – (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE Q Application Accepted By Dale Additional Comments: Phase II Grout Inspection has III Fi al Inspection Inspection BY Date Inspection By `�� Ge D Fee Is Due: ❑ ANNUALLY ED] PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July T &Received By July 31 BASE BILLING REMITTANCE $ REMIT EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKEDAMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER Received by Date Receipt No. Permit No. )[ nuance D to Mailed Delivered APPLICANT--RETURN ALL COPIES TO. ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON.AVE.,P.O.Box 2009 -STOCKTON,CA 95201