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Applications Will Be Processed When Submitted Properly Completed. Be SureTo SignTheAppucaxion. C <br /> APPLICATION <br /> FOR OFFICE USE: <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> strict fora permit to construct and/or install the work herein described.This application is <br /> Application is hereby made to the San Joaquin Local Health Di <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 <br /> 4442 Homer City/Town Stockton <br /> Owner's Name <br /> LUcille Trantham Phone 931-0945 <br /> Address same City <br /> Contractor's Name MOorman' s Water S Stems License# 267696 Business Phone 931.-3210 <br /> Contractor's Address 2120 Wilcox Rd. Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN © RECONDITION 13 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT Eibc <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 /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK 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 t s Water Systems t <br /> Type of Pump submersible H.P. 15 <br /> PUMP REPLACEMENT: �C] State Work Done replaced existing pump with new sub <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San77Joaquinntyordinances, state laws,.and rules and regulations of the San Joaquin Local Health District.Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work fomit <br /> is issued, 1 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 1 will call for a Grout Inspection prior to grouting and a final inspection. �1 " <br /> Signed X Title: &_�/ �r� Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> � Date <br /> Application Accepted By ? <br /> F <br /> Additional Comments: <br /> Phase 11 iGrq nspection as Ili FI Inspection <br /> Inspection By 1 Date Inspection By Date T <br /> { <br /> Fee IS DILE: ❑ ANNUALLY : ❑f.PER UNIT_ �.❑ PER SITE - ❑.EACH ❑ January 1 R Received By January 31 ❑ July 1 &fieceiv REMIT <br /> uly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED * AM60NT,,_ <br /> FEE <br /> LESS � � - <br /> PRORATION <br /> PWS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> S3-- lateReceived by Date Receipt No. Permil No. I swan Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 16,01 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />