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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOCOFFICE USE: APPLICATION , (For Non-Transferable, Revocable4Suspendable) PUMP&WELL t ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY i 1}.► 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 made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address 971. N. Highway '99 City/Town Stockton t Owner's Name Dr. John Silverton Phone931-0758 or 952-2251 Bus. Address City' Stockton I Contractor's Name MoomanesWater Systems License# 67696Business Phone 931-3210 r Contractor's Address 21 20 'WiIC X Rd'- Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No 1 TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ -PUMP INSTALLATION RX PUMP REPAIR❑ ' VIS I REPLACEMENT❑ , Q� DISTANCE TO NEAREST: Septic Tank AZ + Sewer Lines /Gly t Pit Privy ( f1 4 Sewage Disposal Field Cesspool/Seepage Pit 461d'r-Y6, Other t/ a Property Line r I� Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL / /f ❑-INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation E [3DRILLED Dia. of Well Casing 617 DOMESTIC/PUBLIC ❑ DD.IVEN Gauge of Casing 11IRRIGATION GRAVEL PACK Depth of Grout Seal ` ❑ CATHODIC PROTECTION ;k G ROTAF;Y Type of Grout e-1014 7,6F 11-DISPOSAL ' ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed B PUMP INSTALLATION: r Contractor Moorman' s Water Systems Type of Pump submersible H.P. PUMP REPLACEMENT: 11 State Work bone PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: T { Well Diameter Approximate Depth .) I ! Describe Material and Procedure tYC 7 i I hereby certify that I haveprepared this application and that the work will be done in accordance with San Joaquin County ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. a Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit . k VAis issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." ` Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this permit is issued, I shall employ persons subject to workman's compensation laws of California." I will call for a Grout Inspection prior to grouting and a final inspection., r � x Signed X , Q a T � /// Title: !ep- d�Cr-�rp� — Date: (Draw Plot Plan on Reverse Side) j FOR DEPARTME T USE ONLY. 4 t` PHASE I u 'Application Accepted 6 € Date - :�do-. 3 Additional Comments: r. l r ' II o action s > ase'=ate naf tnspection 9 Inspection Date 2 — Inspection 8y, ate Fee IS Due: ANNUALLY ❑ PER UNIT ❑ PER SITE y❑ EACH ❑ January 1 &Received By January 31 w ❑ July 1 &Received By July 31 REMIT --BASE- - 1 EXPLANATION-- BILLING ,_REMITTANCE $ -'AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT I i FEE LESS It PRORATION PLUS PENALTY' OTHER OTHERss Y t r.. - Received by - Date Receipt No. Permit No. Iss a ce Date-k m- 'Mailed Delivered - �- APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES __ 1601 E.HAZELTON AVE.,P.O.Box 2909' STDCKTON,CA 95201 .