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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. �r '•, FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable,Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT � (COMPLETE IN TRIPLICATE) WATER QUALITY MAK /, Application is hereby made to the San Joaquin Local Health District for a 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 Heal th.District. Exact Site Address 'E. Highway 26 City/Town Stockton 10 by'll, Owners Name 1,0ui E. Rtabi nol '_ Phone . 466-9689-gus Address t ` - City Contractor's Name_Moorman I A LJc3te_ t.etRS License#_267696 Business Phone Contractor's Address Emergency Phone rC' Is Certificate of Workman's Compensation Insurance on File With SJLHD7 _Yes No TYPE OF WORK(CHECK): NEW WELL 14 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR 13 6 0 REPLACEMENT❑ / DISTANCE TO NEAREST-. Septic Tank /2•tli Vt Sewer Lines r � Pit Privy Sewage Disposal Field Cessp I�/jS�eepage Pit Other �r Property Lina Private Domestic WePublic Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIALCABLE TOOL Dia.of Well Excavation Gy/rk76 41 ❑ DOMESTIC/PRIVATE DRILLED Dia. of Well Casing G 'fPAr ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing l IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal _�21,�. �— CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: ..�. PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done i 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 for which this I permit is issued, I shall employ persons subject to workman's compensation laws of California." I will call fora Grout Inspection prior to grouting and a final inspection. e Signed X Title: CO--OwnerDate: —5-83 } (Draw Plot Plan on Reverse Side) r , FOR DEPARTMENT USE ONLY PHASE I Application Accepted By Date Additional Comments: Phase It Grout Inspection J as I Finpil Inspection Inspection Bye Date Inspection By Date /1;— /y'"13, } Fee Is Due: ❑ ANNUALLY ❑ PER UNIT_ ❑ PER SITE ❑ EACH '❑ January 1 &Received Py January 31 ❑ July 1&Received By July 31 REMIT BASE EXPLANATION BILLING..! REMITTANCE $ AMOUNT DUE CHECKED - DATE DATE REMITTED AMOUNT FEE LESS — - — - - PRORATION - , PLUS PENALTY OTHER P - - -. -f-' OTHER i Received by Datc Receipt No. Permit No. Isante Date Mailed - Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE-,P.O.Box 2008 STOCKTON,CA 95201