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atiol�sllJtli)I 17CMed yen Submitted Properly.Completed.BeSureTosign Ine„PPTrcauV.T• <br /> FOR OFFICE USE: 11��j�� OO APPLICATION <br /> r on-Transferable,Revocable,Suspendable) PUMP&WELL <br /> Vijj�pA DIS-TRIKVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <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 City/Town <br /> Owner's Name <br /> ,,Mr`OC'�� Phone 931-4512 <br /> AddressCity <br /> Moorman' s Water S sy t�m�icense#257696 Business Phone 931-3210 <br /> Contractor's Name j <br /> Contractor's Address 2120 Wi1COX Rd. Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No n <br /> TYPE OF WORK (CHECK)),-. NEW WELL❑ DEEPEN ❑ RECONDITION 13DESTRUCTION❑ <br /> DV 1 <br /> WELL CHLORINATION ' WELL 1113ABANDONMENT ❑ OTHER PUMP INSTALLATION PUMP REPAIR , <br /> REPLACEMENT 135 C <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 _ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> 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, 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will all for a Grout Inspection prior to grouting and a final inspection. <br /> *Signed X Title: Date: y <br /> (Draw Piot Pfan on Reverse Side) <br /> nay FOR DEPARTMENT USE ONLY <br /> PHASE I {t,JU, <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout inspection Phase III Final Inspection <br /> Inspection B f'W In Date Inspection By y — �y"`� Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH © January 1 &Received By January 31 ❑ July 1 &ReceivedREMIT 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> B; <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No Permit No. I suance D to Mailed Delivered <br /> �.. APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />