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Applications Will Be Processed When Submitted Properly Campit) <br /> . Bel•S�irre`"To MbinThe`Xp I t(on. > <br /> FOR OFFIf-E USE: APPLICATION cc?? 11For Non-Transferable, Revocable,SuspendA U !98I <br /> PUMP&WELL + <br /> ENVIRONMENTAL HEALTH PE IIT I ,; €r ^AL <br /> WATER QUALITY <br /> I'' 1 <br /> (COMjpLETE IN TRIPLICATE) HEAL- !{ EJI�IST <br /> ���T <br /> Application is hereby madeto the San Joaquin Local Health Districtfora permitto construct and/or install thework.he 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 881 W. Bianc-hi - City/Town _ Stn kfnn <br /> 's Name Phone 466-2003 <br /> Owner's <br /> r � 8 City StoC toff <br /> Address Contractor's Name oorman s a er Bu <br /> Systems 931--3210 r-- <br /> License t siness Phone <br /> Contractor's Address 424_3 Crry an Ave. Emergency Phone Bye <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR L$ <br /> REPLACEMENT❑ <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 /> WDOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br />'f 11 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> 4 ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> k PUMP INSTALLATION: Contractor Moormans Water S sterns <br /> l Type of Pump H.P. <br />'i PUMP REPLACEMENT: State Work Done pulled pump and repaired wire <br /> PUMP REPAIR: u State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure 4 <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 /> Homeowner 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 all for a Grout Inspection prior to grouting and a final inspection. 1 i <br /> Signed X Title: ��� � y Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> I <br /> Application Accepted By - t at <br /> Applic <br /> Additional Comments: <br />"I Phase 11 Grou Inspection base 1 I Final Inspection <br /> 3 Inspection By Date Inspection By Date <br />[_ Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received 8y July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> 4 DATE DATE REMITTED AMOUNT <br /> 41 LL) <br /> k W FEE ~� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> . 0THER <br /> Received by Date Receipt No- Permit No. 1S ante D to Mailed Delivered <br /> APPLICANT--RETURN ALL COPIES TO: -ENVIRONMENTAL HEALTH PERMITISERVICESS 1601 E.HAZELTON AVE.,P.O.Boa 2009 - STOCKTON,CA 95201 <br />