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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application: <br /> 'yFCfi QFFIC USE: ce�� aPP �car�oN <br /> 1-1 �2,'g3 (For Non-Transferable,Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT �� /� <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with Sap-,Joaquin CountyOrdinanceNo. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address . WZ0 City/Town Stockton <br /> Owner's Name Cal ii CLQ Horner fay- MY_ [bion RP-.nne..tt Phone 944-0131 DO/ —C)Y_0� <br /> Address ___7_6S2 E_ Mian r,+- - City .9tockton r <br /> Contractor's Name Moorman' s Water Systems License#2_V69 i Business Phone 9_,31—3210 <br /> Contractor's Address 2120 W11CQX Rd. Emergency Phone 8(A <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No `P7 <br /> TYPE OF WORK (CHECK): NEW WELL** DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ O <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines r— Pit Privy <br /> Sewage Disposal Feld&10 1— Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL ^� <br /> ,❑,��INDUSTRIAL ❑ C�98LE TOOL Dia. of Well Excavation <br /> MDOMESTIC/PRIVATE 1E DDRI LED Dia. of Well Casing rl� <br /> ❑ DOMESTIC/PUBLIC DRIVEN Gauge of Casing dre rvy <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION 19 ROTARY Type of Grout Aw hM Ir <br /> ❑ D'ISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: _44 / D <br /> PUMP INSTALLATION: Contractor Moorman' s Water Systems <br /> 1 Type of Pump submersible H.P. <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 /> 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. i <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 /> 1 11 tail for rout Ins ctt rior to grouting and a final inspection. <br /> � <br /> Signed X Lf/ S �' _ Date: <br /> (Draw Plot Plan on Reverse ide) i <br /> FOR DEPARTMENT USE ONLY <br /> ' 4 <br /> PHASE ���� ��J,o, <br /> Application Accepte y Date[ {Zs <br /> Additional Comment <br /> Phase II Grout Inspection ha a III Final Inspection z <br /> Inspection By Date Inspection By Dwe <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 AF ❑ July 1 &Received By July 31 , <br /> REMIT <br /> BILLING REMITTANCE $ .. <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS " <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issu nce at Mailed Delivered <br /> APPLICANT--RETURN ALL COPIES To: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />