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KpppicauonsvviiitaeProcessedWhen Submitted Properly Com <br /> _. P Y P r o Sign Th Application. A <br /> FOR OFFICE USE: APPLICA-�IO - - c <br /> t T(For Non-Transferable, Revocable sa 619 D�� O rl <br /> dat�( 1 <br /> ENVIRONMENTAL HEALTHPERMIT �)N\A �Oc, MP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY 5NN J\A ©v5l , =1� <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or ln� e work herein described.T its s application Is <br /> made in compliance iih S�Cn 'oaquin Count rdin ce No 186 and tti � r and reg ti�ns oft San_Joa uin al ealth ict. ' <br /> Exact Site Address <br /> Owner's Name LaWerenCe Stefani Phone 477'12$1 <br /> Address 5960 x city oe on <br /> Contractor's Name MOOrmari�s 1-r�r Q �:-- License# 93 -321Q <br /> X67696— Business Phone <br /> Contractor's Address 4243 Emergency Phone same <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? x i <br /> Yes No -� <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENTIR <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit <br /> 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 # <br /> ❑ IRRIGATION El GRAVEL <br /> of Casing .I <br /> 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 Moorman' s Water S orstems <br /> Type of Pump submersible H P 2 <br /> PUMP REPLACEMENT: ❑ CY <br /> State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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 /> 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 for which 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 /> io� <br /> Signed X Title: [� r © <br /> V Date: <br /> (Draw Plot Plan on Reverse Side) <br /> 3 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE It <br /> Application Accepted By �� <br /> Additional Comments: <br /> Date V l <br /> Phase Il Grout inspection <br /> Inspection By Phase III Final Inspection ry <br /> Inspection By Date ` Ci "t / <br /> Date <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑,January 1 &Received By January 31 ❑ July i &Received By July 31 F <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE a I <br /> AMOUNT <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received b `'" - `•* <br /> Y Oate - Receipt No. Permit No, Issua ce D to _ Mailed- Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES- <br /> .� .,x1601 E.HAZELTON-AVE.,-P.D.Box 2009 STOCKTON,CA 96201 <br />