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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 /> (COMPLETE IN TRIPLICATE) WATER QUALITY <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 4566 Virgil: City/Town S#-6cktr;r <br /> Owner's Name - _ 4,. .� -"' Phone 463-2141 <br /> Address E. Noble; St., City Stockton <br /> Contractor's Name Moorman' s. Water -SySteMS License'# 267696 Business Phone 931-3210 <br /> Contractor's Address 2120'Wilcox -Rd: Emergency phone 1 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ r .. RECONDITION❑ r DESTRUCTION[]- <br /> WELL <br /> ESTRUCTION❑'WELL CHLORINATION ❑ 7 - WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ 1� <br /> REPLACEMENTL <br /> ) <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 <br /> z ❑ INDUSTRIAL- _ 0 CABLE TOOL �_�,r.. 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 i Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL t1 Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Moorman' s Water Systems <br /> Type of Pump submersible <br /> PUMP REPLACEMENT: X❑ State Work Done pulled existing pump and replaced with HP <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. <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 /> t <br /> I will call fora Grout Inspection prior to grouting and a final inspection <br /> I r l <br /> Signed X r _�'17 7��r'-� : Title: _Z.9 ` cv�r C/2� Date: .. <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY r —„ <br /> PHASE Ir <br /> I <br /> Application Accepted By t_ Date <br /> Additional Comments: /0&7;re .�' bc .Svvov S,Eek <br /> Phase 11 Gr It InspectionInspection <br /> JT <br /> Inspection By �" Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Rec6ved By July 31 <br /> I F <br /> BILLING REMITTANCE $ REMIT <br /> BASE ExPLANATION - AMOUNT DUE CHECKED it <br /> } DATE DATE REMITTED AMOUNT �. <br /> FEE -- <br /> LESS <br /> PRORATION ` <br /> _ PLUS <br /> PENALTY I <br /> OTHER f <br /> OTHER <br /> Received by Date IF Receipt No.--. Permit No. Is uance ate Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />