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Ap I logs%WI 6WPPoocelse&Vh bmitted Properly Completed. Be Sure To Sign The Application. <br /> f FOR OFFICE USt-Y _ ��1 ftlAPPLICATION <br /> JUL 22 19€x} Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> SAN JOf U1N Ed�(I�ONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) ySE�LTH DISTRtIICT WATER QUALITY \F <br /> I Application is hereby-madetothe an oaqulnLocalHealthDistrictforapermittoconstructand/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 Jo4qn L aI #}��eeaith District. \. <br /> Exact.Site Address 3087 E. Fremont City/Town OCLOYT <br /> Owner's Name Mrs. Al.ra Stevens Phone 952-0590 <br /> Address 8700 N. West Lanespace. 157 City Stockton pig <br /> Contractor's Name Moorman' s Water SyStEDMS License# 267696 Business Phone 931--3210 O <br /> 4243. Cheri and Ave Same <br /> I Contractor's Address y Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No -i <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR El <br /> REPLACEMENTEZ <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 /> F IN <br /> USE TYPE OF WELL n T T <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 Seal Cf <br /> I ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> r PUMP INSTALLATION: Contractor r <br /> Type of Pump submersibe z <br /> H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done rep aced ex1S ing pump Wit z <br /> HP <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> r Describe Material and Procedure <br /> 4 <br /> I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> k 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 I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X F Title: — ,( � m Date: <br /> (Draw Plot Plan on Reverse Side) r <br /> ORD ARTMENT SE ONLY <br /> M PHASE 1 <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection P se III Final Inspection_ <br /> Inspection By Date Inspection B Date LJ <br /> } Fee Is Due: ❑ ANNUALLY ❑ PER UNIT (FPER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> # BILLING REMITTANCE <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> of <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> z3 o <br /> Received-by _ Date Receipt No. Permit No. - Iss ante Date Mailed Delivered <br /> . APPLICANT—RETURN ALL COPIES TO:' ENVIRONMENTAL HEALTH PERMIT/SERVICES r►p;�� 1601 E.HAZELTON AVE.,'P.O.Box 2009 STOCKTON,CA 95201 / <br />