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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferabie,Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL-HEALTH PERMIT <br /> WATER QUALITY'1-11.1.;, y # , t <br /> (COMPLETE IN TRIPLICATE) v:. ; <br /> 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 <br /> 3 made in compliance with.San.Joaquin County Ordinance No. 1862 and the rules and regulations of the4San Joaquin Local Health District. <br /> y 9050 'Hildr eth Lan+; "` ," " '-` City%Town Stockton - <br /> Exact Site Address <br /> Dr.-. BRVon on Ecker. t " I:Y3. ? >,;>' Isr . ' K :r <br /> Owner's-Name tr > Phonee, �. µ rpt <br /> Address same--: _.� -fes:tfi ' _ yytt'1 t � City <br /> Contractor's Name Doorman' s Watex OS stems License#, F] business Phonet <br /> ':`�. .� ' �..,.i.e, " ' EmerQnC Phoned �` n.. <br /> Contractor's Address 2120 W1, r- g y <br /> S <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X w No — <br /> TYPE OF WORK(CHECK): NEW WELL❑ 'DEEPEN ❑ RECONDITION❑ _ 'DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER.❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑. _ 4q <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> £ Sewage Disposal Field Cesspool/Seepage Pit Other <br /> 1 _ <br /> Property Line Private Domestic Well Public Domestic Well <br /> t _ - <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia.-of Weil,Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED a Dia. of Well Casing ' <br /> ❑ DOMESTIC/PUBLIC — ❑ DRIVEN `" - °' Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 0 <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> 11 DISPOSAL 11 OTHER Other Information r <br /> ❑ GEOPHYSICAL a Surface Seal Installed By: O <br /> PUMP INSTALLATION: Contractor Moorman" s Water S sterns <br /> j Type of Pump tilled eXiStinl H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: -W State Work^Done Peer <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure ' 1� <br /> � 1 � <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 Locale 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." k <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." 4 <br /> I-will call fora Grout Inspection prior to grouting and a final inspection. <br /> Tule: Date: <br /> Signed X i <br /> (Draw Plot Plan on Reverse Side) i <br /> i FOR DEPARTMENT USE ONLY K <br /> _ - g <br /> PHASE I - Dated <br /> _ — <br /> Application Acceptedy # ' <br /> Additional Comments: = <br /> Pfiase II Grout inspection .tx' Phase Ili Final Inspection <br /> Inspection B <br /> Inspection By Date yBy <br /> �*`✓ti---- bate Z <br /> Fee Is Due: 11 ANN UALLY PER UNIT. ❑-PER SITE' ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREM17uly 31 <br /> BASE EXPLANATION BILLING- REMITTANCE- AMOUNT DUE CHECKED F <br /> r DATE DATE REMITTED AMOUNT , <br /> FEE <br /> t � <br /> LESS <br /> PRORATION <br /> PLUS ' <br /> PENALTY - <br /> F OTHER <br /> OTHER <br /> '3 Sd �j . _.. <br /> Received by Date Receipt No., Permit No — lssuan a Date Mailed - Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />