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ilication .Will Be Processed When Submitted Properly Completed. Be SureToSign TheApplication. <br /> APPLICATION <br /> (For Nan-Transferable, Revocable, Suspendable) .. <br /> _�'""' `� ` PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <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 /> made in compliance with San Joaquin County Ordinance No.'1862 and the rules and regulations of the San Joaquin-LocaLHealth District. <br /> Exact Site Address 6553 Waterloo-Rd. - City/Town -Stockton <br /> I FranMedina Phone 933_--35 23 <br /> Owner's Name k - <br /> Address same. _ City <br /> Contra'ctor's Name Moorman` s.. `'eater Systems License# 267696 Business Phone 931..-3.21.0 <br /> Contractor's Address 4243 Cherryland Ave. Emergency Phone same <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN Cl RECONDITION❑ DESTRUCTION❑ <br /> WELL IiCHLORINATION ❑ WELL ABANDONMENT © OTHER 11 PUMP INSTALLATION 6X PUMP REPAIR❑ <br /> REPLACEMENT 13 <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 YN <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 r ❑.ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 13 GEOPHYSICALSurface Seal Installed By: s <br /> PUMP{INS LLATIO • Contractor MOOrman`r s Water Systems <br /> . Type of Pump submersible H P. 3/4 <br /> PUMP',REPLACEMENT: State Work Done pulled existing l_mp and installed. new <br /> 1 <br /> PUMP REPAIR: ❑ State Work Done _ — <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth �l <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 /> ordinancesi state laws, and-nu'les.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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will calk for a Grout Inspection prior to grouting and a final inspection. a <br /> 5ignetl X e `.� Title: !�1 — Date: a'�>U" f_ _ 1;? <br /> f (Draw Plot Plan on Reverse Side) <br /> {� FOR DEPARTMENT USE-ONLY f.. <br /> 11 PHASE I G <br /> (Application Accepted By °"`^ Date ? <br /> Additional Comments: <br /> Phase 11 Grout inspecll n Phase~ 11Fi at tnspection <br /> Inspection By Date Inspection By / ate ® � <br /> ,, <br /> Fee Is Due: I-] ANNUALLY. El PER UNIT ki 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 DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PR A VON # <br /> wPLUS <br /> PENALTY <br /> �r OTHER i �/1►- a <br /> OTHER <br /> �I Received by _ pate `x �Rece�pt No. Permit No Issuance Date Mailed Delivered <br /> STOCKTON,CA 952111 <br /> APPLICANT—R TURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 <br /> �,- <br />