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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable;Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) ..,<. r <br /> Applicationis 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 <br /> City/Town <br /> Stockton <br /> Owner's Name <br /> I,f:?S le Miltun:r Phone 931-200$ <br /> Address same. ::¢ tc :,;�y a�+ City' W <br /> Contractor's Nam,Moorman 9 sJ�Water Systems. License# 267696`- Business Phone � 1-3210 <br /> Contractor's Address 2124 Wilcox- Rd. Emergency Phone <br /> ,. t <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? ' Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION IRX PUMP REPAIR❑ <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 I <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-Sea] <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 Systems <br /> Type of Pump S11 ersa: e f LID. a N <br /> PUMP REPLACEMENT:, EI State Work Done replaced existing pump with new i aHP <br /> PUMP REPAIR: <br /> ❑ State Work Done r <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> t <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 forwhich this <br /> I <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. r l <br /> Signed X Title: A� Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � T-7 <br /> Application Accepted By Date <br /> Additional Comments: r <br /> Phase 11 Grout Inspection w Phase fit Final Inspection <br /> Inspection By Date Inspection By� Date y <br /> S <br /> t <br /> Fee Is Due:'❑ ANNUALLY. ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 El July 1 &Received By July 31 <br /> — REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE L - <br /> LESS <br /> fff PRORATION <br /> h PLUS <br /> PENALTY 1 <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Iss ante ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 95201Q77- <br />