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AP IdW*01 kW Pra..asefi 3itrh bmitted Properly Completed.Be Surer Slgn The Applicatio . <br /> FOR OFFICE USE: . _ "APPLICATION <br /> SEPU s <br /> 10r Non-Transferable,ftevocabie,,Suspendable) <br /> ` x M�y (1F�ONMENTAL HEALTH PERMIT <br /> �, . PUMP& �7� <br /> $AN JOAQ'UIN LUGAL ' <br /> (COMPLETE IN TRIPLICATE) HEALTH DISTRICT WATER QUAUTY <br /> Application is herebymade tothe5an Joaquin Local Health District fora permitto construct and/or Install the work herein described.This application is <br /> made in compliance with fan Joaquin County Ordinance No.1862 and the rules and regulations of the San Joaquin Local Health District. x <br /> Exact Site Addr ss 7600 windmill Cdve Rd <br /> City/Town Stockton <br /> Owner's Name Ray Everett '(Windmill Cove) Phone 466-3691 -948-6995 ' <br /> i <br /> Address City r <br /> Contractors Name Moorman r s Water Systems Licer1se267696 Business Phone 931-321.0 <br /> Contractor's Address 4243 Cherr land Ave Emergency Phone 1 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHO? Yes X No J <br /> TYPE OF WORK(CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCT10N❑ ^- <br /> WELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION SE PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank - _�� Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other_ <br /> Property Line Private Domestic Well Public Domestic Well <br /> ENDED USE TYPE OF WELL <br /> VGEOPHYSICAL <br /> STRIAL ❑ CABLE TOOL Dia.of Well Excavation _ <br /> ESTiC/PRIVATE ❑ DRILLED Dia.of Well CasingESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ODIC PROTECTION ❑ ROTARY Typwof Grout <br /> OSAL ❑ OTHER Other Information <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor t <br /> Type of Pump dt!5 s' H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP'REPAIR: ❑ State Work Done C7 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws,and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Conlractors hiring orsubtontracting signature certifies the following:"I certify that in the performance of the work for which this ) <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California," ] <br /> I will call for a Grout Inspection prior to grouting and a Ifnal Inspection. <br /> Signed X Title:_� - Q-l�cr7cQJ1a� _ Date- <br /> (Draw Plot Plan on Reverse Side) <br /> E0J1 DEPARTMENT USE ONLY <br /> PHASE 1 '®_�k <br /> 4 <br /> Application Accepted By Date <br /> Additional Comments: ,t <br /> Phase tl Grout inspectionhas 111 Fin Inspection <br /> Inspection Elyti fa Date Inspection fly Date Awfnv <br /> t <br /> Fee Is Due:.❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Recelve By January 31 ❑ JUIy 1'&Received By July 31 <br /> BILLING REMITTANCE ; <br /> REMITTED REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED Y <br /> 1 - DATE DATE, AMOUNT 11j <br /> FEE , � <br /> i <br /> LESS <br /> PRORATION f <br /> PLUS >� <br /> PENALTY <br /> OTHER <br /> 3 <br /> `3 Received by Date Receipt No. Permit No. I Issuan DaE - .Melted Delivered ' <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E'HAZELTON AVE.,P.O,Sar 2909 STOCKTON,CA 95201 <br />