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Applications Will Be ProcessedWhenSubmitted Property Lompieteary rLP01911 1 <br /> �FFICE USE: <br /> APPLICATION <br /> FOR <br /> (For Non-Transferable, Revocable, S d ble} �R P&WELL <br /> ENVIRONMENTAL HEALTH P TXT� <br /> WATER QUALITY 3�g.��O Fr <br /> (COMPLETE IN TRIPLICATE) �u <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or indbl.tkfe. rkherein described. his application is <br /> made in compliance withc' n..J.oapA, ..Cquuntj0rrldiinnance No. 1862 and the rules and regulations of the��CC``San Joaquin Local Health District, <br /> Exact Site Address 1 6- Wr1 L City/Town <br /> William Wakeland 948-9685 <br /> Owner's Name Phone <br /> P.O. Box City O° on <br /> Address O� <br /> Contractor's Name Mo°rman s Water Sys emS License# Business Phone <br /> Contractor's Address <br /> 42 C errY ari AVe. Emergency Phone She <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHI7? Yes sr No <br /> TYPE OF WORD (CHECK): NEW WELL 13DEEPEN ❑ RECONDITION 11DESTRUCTION❑ <br /> WELL CHLORINATION 11WELL ABANDONMENT ElOTHER C1PUMP INSTALLATION ❑ PUMP REPAIR <br /> RFRt.- w&*Nffi–" <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 f <br /> ❑ GEOPHYSICAL Surface Seal Installed By: 1 <br /> PUMP INSTALLATION: Contractor Moorman' s Water Systems <br /> Type of Pump, H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done— <br /> PUMP <br /> one 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, 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 /> I will call for a Grout Inspection prior to grouting and a final inspection. /, �y <br /> Signed X _ Title: ���. ��/� Date: <br /> - 'd — <br /> (Draw Plot Plan on Reverse Side) <br /> h <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 94 <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection P s Final Inspection <br /> Inspection By Date Inspection B r Date <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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT OUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> j <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 162_ -1 �-� 1� � <br /> Received by Date Receipt No. Permit No, . I Issuancd 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 />