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AWqNioYW*018VMr—ocelse"h bmitted Properly Completed. Be Sure To Sign The Applicatio . <br /> FOR OFFICE USE: �,p APPLICATION <br /> SEP B 1%4r Non-Transferable,Revocable,,Suspendable) r . <br /> �yy PUMP& ,- LL, <br /> SAN J A I iN �E,�1,/�RLONMENTAL HEALTH PERMIT A <br /> v� WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) HPAL.TH ©ICTRICT <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 7600 Windmill Cove Rd City/Town Stockton x <br /> Owner's Name <br /> Ray Everett ,(Windmill Cove) Phone 466-3691 -948-6995 <br /> 1 <br /> Address City r <br /> Contractor's Name MOOrman is Water SystemS_ License267696 Business Phone 931-3210 <br /> Contractor's Address 4243 Cherryland AVE Emergency Phone <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 F91 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 /> a <br /> ENDED USE TYPE OF WELL <br /> 90DO <br /> STRIAL ❑ CABLE TOOL Dia. of Well Excavation ) <br /> ESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ATION ❑ GRAVELPACK Depth of Grout SealODIC PROTECTION ❑ ROTARY Type,of Grout <br /> OSAL © OTHER Qther Information <br /> PHYSICAL Surface Seal Installed By: g <br /> PUMP INSTALLATION: Contractor r i <br /> Type of Pump '+ r" H.P. 1 <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 /> 1 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 call for a Grout Inspection prior to grouting and a final inspection. / <br /> Signed X i i� n d-s1 Title: 4� — ��r74�L/. Date: d <br /> (Draw Piot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY - <br /> PHASE I D <br /> Application Accepted By Lx1L4�� Date , <br /> Additional Comments: f <br /> Phase 11 Grout Inspection Phas I11 Fin Inspection <br /> Inspection By Date Inspection By Date <br />` 7 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Receive By January 31 ❑ July 1 &Received By July 31 r <br /> BILLING REMITTANCE $ - REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE, REMITTED y <br /> AMOUNT j4! <br /> FEE <br /> v L <br /> LESS t" <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> iY Received by - Date Receipt No. Permit No. I Issuanc Date - -Mailed Delivered - <br /> 1l <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E:HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />