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naWn'$+k%eMroc'es's_eJd Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: SEP CJD APPLICATION <br /> t» or Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> Sjlpj J AOUIN L&!lIAIILRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE iEALTH DISTRICT 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 Local Health District. <br /> Exact Site Address 10950. N. West Lane City/Town Stockton <br /> Owner's Name Charles, Sherr0 Phone 477-5211 <br /> Address . .1,r,; .0^ .,_ __" I City- r:. . <br /> Contractor's Name MOorItLan t s` Water SyStetns tLicense#267 696 Business'Phone 931-3210 <br /> Contractor's Address Emergency Phone t' t <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No Y <br /> TYPE OF WORK (CHECK):7 NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT�❑,_OTHER�,❑__ PUMP INSTALLATION.5a„.,..,P-UMP REPAIR❑ <br /> REPLACEMENT,Q <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field y Cesspool/Seepage Pit Other a <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 - w <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Moorman' s Water S stems <br /> Type of Pump submersible H.P. l i <br /> PUMP REPLACEMENT: 7E7 State Work Done -pulled existing Aum and replaced With new one <br /> PUMP REPAIR: ❑ State Work Done = <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure T <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. l7 <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit a <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 call for a Grout Inspection prior to grouting and a final inspection. ,/�' <br /> k <br /> Signed X _ e- ��' a Title: rpm G' Date:� ' I r <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY 4 <br /> PHASE - <br /> Application Accepted B <br /> ' Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final Inspectionp <br /> n. Date Inspection By <br /> Inspection By_M <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT © PER SITE ❑ EACH ❑ January 1 &Received By January 31 July 1 &Received By July 31 <br /> - - - REMIT fili <br /> BASE EXPLANATION BILLING REMITTANCE $ - AMOUNT DUE CHECKED I <br /> DATE DATE REMITTED AMOUNT <br /> cr. `. <br /> FEE <br /> i <br /> LESS <br /> PRORATION E <br /> PLUS <br /> PENALTY ' <br /> OTHER <br /> OTHER w <br /> Received by Date- `Receipt No-' Permit No. _ "Issua- e Dat Mailed. Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />