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cati II P _ ed n Submitted Properly Completed. Be Sure To Sign aApplication. <br /> tOFFICF USE: <br /> 17 TIM APPL'1CATION <br /> � <br /> (Fof Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> SAN JOAQ'UIN LOCAL - <br /> HEALTH DISTRIGEf VIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) I WATER QUALITY <br /> 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 <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address „a, 4904 Hildreth Lane City/Town Stockton <br /> Owner's Name RO FLeale a Phone 93 -2348 <br /> Address City <br /> Contractor's Name <br /> ' s Water Systems License# 267696 Business Phone 931-3210 <br /> Contractor's Address 424' Ch rryi And AVe, Emergency Phone Same <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No + <br /> j TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ 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 /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> El DOMESTIC/PUBLIC 11DRIVEN Gauge of Casing <br /> I <br /> ❑ IRRIGATION C1 GRAVELPACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout - <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Moorman' S Water Systems <br /> Type of Pump 1 HP submersible H.P. l z <br /> PUMP REPLACEMENT: ❑ State Work Done replaced ex.isting pump With new one <br /> I -� <br /> PUMP REPAIR: ❑ State Work Done <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 /> Contractor's hiring or sub-contracting 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 final inspection. <br /> �11t <br /> Signed X - _ ..iTltle: _ g:99 r-�it-/. ..Date: . 9_ S+"�(J <br /> i (Draw Plot Plan on Reverse Side) <br /> t FOR DEPARTMENT USE ONLY <br /> PHASE I 1 Q— A40 <br /> Application Accepted *Phasel <br /> Date <br /> Additional Comments: <br /> out Inspection r9hase Ill Final Inspection <br /> Inspection By <br /> [Z__ Date 4 <br /> Inspection By ' Date <br /> I <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION <br /> M DATE DATE REMITTED �i AMOUNT <br /> l <br /> �FEE�S <br /> k PRORATION _ <br /> PLUS <br /> PENALTY <br /> r <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No Iss ante Datex Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO:s ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O. 2009- STOCKTON;CA 95201'"' <br />